WELSH IN THE HEALTH SERVICE The Scope, Nature And Adequacy Of Welsh Language Provision In The National Health Service In Wales

WELSH IN THE
HEALTH SERVICE:
The Scope, Nature
and Adequacy of
Welsh Language
Provision in the
National Health
Service in Wales

Andrew Misell
2000

NOTES ON THE LANGUAGE OF THIS REPORT:

This is the English version of a report published
bilingually. Where a quotation is taken from an English
language source, it is presented in the original
language in both versions of the report, to preserve the
impact of the original and to facilitate easy reference to
the original source for anyone wishing to carry out
further research, Where quotations are drawn from
bilingual sources, such as official Welsh Office
publications, they are presented in their appropriate
language in each of the two versions of this report, The
vast majority of interviews for this report were
conducted in Welsh, Where the spoken words of
interviewees are quoted, this is done adhering as
closely as possible to the exact wording used by the
interviewees to preserve the impact of the original. For
this reason, quotations from interviews are given in the
original language, with translation into English where
necessary in the English version of the report,

CONTENTS

FOREWORD

O ver recent years the Welsh Consumer Council has become increasingly
involved in the debate on the role, status and use of the Welsh Language
throughout Wales. This interest rests on the fundamental premise that
language is a real consumer issue, in addition to being an issue of culture,
politics, identity and of course communication.

The Welsh Consumer Council set about defining the consumer interest in
language in its 1996 report, Welsh as a Consumer Issue. That report emphasised
how and why the opportunities for using the Welsh language be considered
from the view of the consumer. In general, service providers are well equipped
to look after their own interests - the consumer by comparison is often weak.

It is this theme that is picked up in this report - Welsh in the Health Service:
The Scope, Nature and A dequacy of Welsh Language Provision in the National
Health Service in Wales. While the report recognises that, in many instances,
Welsh language service provision is about providing equal opportunities and
ensuring a high quality, consumer sensitive service, it also identifies groups for
whom service provision in the first language is a clinical necessity.

The report concludes that in the case of Welsh-speaking patients, there are
instances when they cannot be treated effectively except in their first language,
or in both their languages. This is especially true in the case of those receiving
speech and language therapy, and for the following key groups:

❖ people with mental health problems.

❖ people with learning disabilities and other special needs.

❖ older people, and
❖ young children.

The report contains many recommendations and calls for a fundamental change
of approach on the part of the NHS in Wales. The report also calls for greater
leadership from the National Assembly itself. Most importantly, the report calls
for a change of thinking. It must become clear that the responsibility for
ensuring that the language used within the health service is one with which
everyone is comfortable rests with service providers and not with consumers.
Welsh in the Health Service: The Scope, Nature and Adequacy of Welsh
Language Provision in the National Health Service in Wales is an authoritative
piece of research. The author, Andrew Misell, presents a strong and well-argued
case for change in the NHS in Wales. The report makes serious reading and
demands attention from the highest level of government in Wales.

Dr Chris Llewelyn, Senior Policy and Development Officer
Dr Nich Pearson, Director
Welsh Consumer Council

Chapter 1 - INTRODUCTION AND BACKGROUND

T his project was begun on 10 August 1998 as a
6 month survey of the nature, extent and
adequacy of the provision within the National
Health Service (NHS) in Wales for Welsh speaking
patients and their families. It forms part of the Welsh
Consumer Councils' ongoing work to promote the
Welsh language as a medium for accessing services in
Wales, and is also part of the Council's ongoing
commitment to securing the rights of vulnerable
consumers, particularly in difficult and stressful
situations as often encountered in the field of health
care. On account of the short time available to
complete the research work, this is in no way a
comprehensive review. In spite of this, the author
hopes that it does provide a clear and fair picture of
the present situation of the Welsh language in the
NHS in Wales.

This report arose in part from anxieties concerning
the attitudes of some health care providers towards
the provision of services in patients' chosen
language(s), in particular the view that language
specific provision is an added extra which can be
included or dispensed with at will. It was felt also that
the definition of quality of service was often very
narrow, and that there was a defi nite need to give
patient language choice its due consideration as a
significant factor in the process of treating the "whole
patient", in accordance with the latest Medical ideas.

A revealing example of this narrowness of definition
was seen at the beginning of the project in the
response of one Community Health Council to an
enquiry about Welsh language provision in the Health
Service:

"In general, I feel that patient concern about
quality of services relates to clinical and care
issues and that most people would not be
aggrieved if staff, be they medical, nursing or
administrative, were unable to converse in the
patient's language of choice."

Contrary to this, it is the author's belief that we
cannot differentiate so neatly between clinical and
care-related questions on the one hand, and issues of
language choice on the other. The evidence collected
shows clearly that it is necessary to consider the
whole range of needs which patients have, if they are
to receive effective and successful treatment.

Various aspects of the NHS were looked at, covering a
wide range of services provided in the home, in local
surgeries, and in major hospitals. The aim was to look
not only for faults and failings, but also for examples
of good practice in different parts of the Health
Service which could be transferred to other parts
where provision is failing or in some way inadequate.

It is not the author's intention to attribute blame to
anyone or to search for scapegoats: rather, to look
constructively at what is currently being done, and at
what could be done within the staffing and resource
constraints placed on the NHS. Neither is it intended
to undermine or undervalue the dedicated work of the
thousands of non-Welsh speaking staff working in the
Health Service in Wales. It should be noted from the
start that during the research for this report, nothing
but praise was to be heard from health care users for
the overwhelming majority of NHS staff, be they
Welsh speaking or non-Welsh speaking.

Although some consideration was given to the
various Welsh language policies and statutory Welsh
Language Schemes which have been prepared by
health care bodies, attention was devoted above all to
the practical usefulness of the Welsh language
provision which is available to consumers in reality.
Whilst doing this, two main categories of Welsh
speaking patients were identified:

(i) Those for whom Welsh language provision is a
clinical need when they are receiving treatment;
either because it is not possible to communicate
effectively with them except in Welsh, or
because their treatment deals directly with their
language or speech faculties. Within this first
category, 4 key groups were identified, and their
particular needs and requirements are described
in Section 7.2.

(ii) Those whom it is a matter of good practice to
provide with services in their chosen language
where that is possible.

At the end of the report, a number of practical and
realistic recommendations are presented, based on a
recognition of the complex nature of the linguistic
situation in Wales and the genuine problems facing
health care providers as they seek to provide
appropriately for a bilingual population. The report
focuses on the health sector but the study is relevant
to other areas of public service. That is to say, there
are lessons within the report for other sectors as well.

The survey carried out in March 1995 by NOP on
behalf of the Welsh Language Board showed that
there is substantial support in Wales for the increased
use of Welsh in the public sector, with 83% of those
questioned believing that every public body should be
able to deal with people in Welsh and English. The
aim of this report is to build on the basis of this
goodwill towards the language, and move on towards
a National Health Service which will be better able to
respond to the linguistic needs of the people of Wales.

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

7

Chapter 2 - RESEARCH METHODS

A methodology was chosen for this project on
the basis of social science research
conventions, taking into consideration
methods which have worked well in past Welsh
Consumer Council Studies and adapting them to this
particular field of research. The main emphasis was
placed on seeking the opinions of ordinary
consumers, and to a lesser extent the opinions and
ideas of medical professionals and researchers and
specialists in the fields of health care and/or
language. This information was placed in the context
of the corpus of research work already completed in
the two fields of health care and language.

2.1 Desk Research

The desk research continued through most of the
period of the project as more and more matter came
to hand. A large number of official documents
relating to the Welsh language, and to various aspects
of health care, were looked at, including every
statutory Welsh Language Scheme published by health
care bodies so far. A number of articles and reports
dealing with Welsh language matters but not directly
with health care were studied, and vice versa several
documents concerned with health care but not
specifically with language questions. It is intended to
transfer some of the lessons already learnt in other
fields where language has been a topic of discussion,
and also refer to current ideas regarding quality of
health care and their relevance to any consideration
of bilingualism in the NHS in Wales.

A comprehensive bibliography is to be found at the
end of this report.

2.2 Contacts with Key Individuals and
Institutions

The following bodies were contacted:

Age Concern Cymru

British Stammering Association

Canolfan Bedwyr, University of Wales, Bangor

Cefn (language rights movement based in Caernarfon)

Community Health Councils (every one in Wales)

Cymdeithas Ddeintyddol Gymraeg (Welsh speaking

Dentists' Society)

Cymdeithas Feddygol Gymraeg (Welsh speaking
Medical Society)

Cymdeithas yr laith Gymraeg (Welsh Language
Society)

Federation of Welsh Young Farmers Clubs
Institute of Rural Health
National Carers Association

Mencap in Wales
M enter Cardiff
M enter Cwm Gwendraeth
M enter Hiraethog
M enter Maldwyn
Menter Taf Elai

Mercator (Information and Document Network for the
Lesser Languages of the European Union)

Merched y Wawr
Mind Cymru

Mudiad yr Ysgolion Meithrin

National Schizophrenia Fellowship

PIGO - Committee for Bilingualism in Ogmore

Qualifications, Curriculum and Assessment Authority

for Wales

Royal College of Speech and Language Therapists

Stroke Association

Urdd Gobaith Cymru

Welsh Language Board

Women's Institute

The following bodies were contacted by letter
but did not respond:

Anglesey Community Health Council

Brecon and Radnor Community Health Council

Carmarthen / Dinefwr Community Health Council

Conwy Community Health Council

Derwen and Pembroke NHS Trust

Dyfed Powys Health Authority

Gwynedd Hospitals NHS Trust

Maelor Wrexham Hospital Trust

Montgomeryshire Community Health Council

North East Wales Community Health Council

Powys NHS Health Care Trust

Vale of Clwyd Community Health Council

In-depth, face-to-face interviews were
conducted with the following 20 key
individuals:

Arvind Bhatt, Minority languages researcher in the
Leicester area.

Cefin Campbell, Director of Mentrau laith Myrddin

Eleri Carrog, Executive Secretary of the language
rights movement Cefn

Dr Carl Clowes, Medical Director, Powys Health Care
Trust

WELSH IN THE HEALTHSERVICE:

Chapter 2- Research Methods

Dr Dorothi Clowes, Speech and Language Therapists
Advisor in Wales

Elaine Davies, Freelance researcher and author in the
field of social work

Karen Davies, Programmes Co-ordinator, School of
Health Science, University of Wales, Swansea

Jeremy Evans, Research student, Welsh Department,
University of Wales, Cardiff

Dr Dafydd Huws, consultant psychiatrist
Rhian Huws Williams, Head of CCETSW Cymru

Twm Jones, Mental health nurse in theArfon area,
and one of the founders of The Gwynedd Welsh¬
speaking Mental Health Workers Group

Professor Marilyn Martin-Jones, Professor of
Bilingualism and Education, University of Wales,
Aberystwyth

Sian Munro, Speech and language therapist and Head
Lecturer, Faculty of Community Health Sciences,
University of Wales Institute, Cardiff (UWIC)

Sian Pugh Davies, Midwife in Singleton Hospital,
Swansea, and researcher into the Welsh language in
the field of health care

Gwerfyl Roberts, Lecturer with Responsibility for
Development Through the Medium of Welsh, School
of Nursing and Midwifery Studies, University of
Wales, Bangor

M ik Standing, Equality Officer, Disability Wales

Gwenan Thomas, Midwife in the Lampeter area and
health care researcher at the University of Glamorgan

Dafydd Wigley, Member of Parliament for Caernarfon

Professor Colin Williams, Research Professor, Welsh
Department, University of Wales, Cardiff

Hywel Williams, Cymad, Rural Resources Centre,
Porthmadog

Telephone interviews were conducted with the
following 4 key individuals:

Delyth Byrne, Welsh Women's Aid

Gareth Kiff, Former Chairperson of Cymdeithas yr
laith Gymraeg

ElfrysJones, Language Officer, North Wales Health
Authority

Dr Glyn Williams, Research Centre Wales, University
of Wales, Bangor

2.3 Interviews with Health Care Users and Staff

Between 19 October and 9 December, face-to-face
confidential interviews were held with 43 people (in
addition to the 24 key individuals named above).

Most of the interviewees were ordinary users of
various parts of the National Health Service, although
they also included a number of health care
professionals and several retired former health care
workers. Interviewees were questioned in an open-
ended, semi-structured fashion about any particular
experiences they wished to discuss, and also about
their general experiences as Welsh speakers going
through the health care system. A list of set questions
was drawn up for these interviews to prevent them
becoming directionless conversations, but not every
interviewee was asked every question, as the intention
was to encourage consumers to talk about their own
personal experiences, rather than to collect data to
analyse statistically. Health care workers and former
workers were questioned about their experiences of
using Welsh in their work, and also about their
experiences as patients.

Interviewees were recruited in 3 main ways:

(i) An open letter was published inviting health
care workers and users to take part in the
project. This letter appeared in the following
daily newspapers: The Western Mail, The Daily
Post, South Wales Argus, South Wales Echo,
South Wales Evening Post, and also in the two
Welsh language weeklies, Y Cymro and Golwg.
Versions of the letter were also sent to all the
monthly Welsh language papurau bro, and to
every weekly newspaper published in Wales. A
short article about the project was published in
Big Issue Cymru, and it received some coverage
on the BBC current affairs radio programme
Post Prynhawn.

(ii) The National Carers Association and the
National Schizophrenia Fellowship agreed to
distribute open letters explaining the project to
all of their known Welsh speaking members,
inviting them to take part. The mental health
charity M ind Cymru provided a list of all their
county organisers, and information about the
project was sent to all of these to be passed on
to members.

(iii) A number of people were contacted through
personal networks, or following suggestions by
interviewees already contacted by the two
methods described above.

In addition to face-to-face interviews, 7 telephone
interviews were conducted with health care users and
staff. Detailed letters were also received from 4 people
who were not personally interviewed discussing their
experiences. A number of people who had previously
contacted the Welsh Language Board in connection

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

9

Chapter 2- Research Methods

with Welsh language provision in the Health Service
were also contacted, and their permission was
obtained to study their evidence to the Board.

It was noticed that the same themes tended to come
up fairly consistently during interviews with patients
and staff, and these are described in detail in

Chapter 7: Discussion Topics.

2.4 Observation Work in Hospitals

As a small test of the extent to which the Health
Service in Wales gives consumers the impression of
welcoming the use of Welsh, observation work was
carried out in the reception areas of 7 large general
hospitals across Wales. During observation work the
following things were looked at:

(i) The response of reception staff to simple spoken
enquiries in Welsh.

(ii) The frequency, quality and clarity of bilingual
signs.

(iii) The bilingualism or otherwise of pamphlets,
information leaflets available to the public.

(iv) The bilingualism of posters and notices on
noticeboards.

(v) To what extent Welsh language periodicals
(magazines and newspapers) were available in
the shop(s) provided for users and staff within
the hospital premises.

2.5 Beaufort Research Questionnaire Survey

In addition to the qualitative research described
above, the Beaufort Research company was
commissioned to carry out a statistical study of
consumers experiences of using the Welsh language
in the National Health Service. This took the form of
a questionnaire survey of 452 people, carried out in
December 1998.

10

WELSH IN THE HEALTHSERVICE

Chapter 3 - THE WELSH LANGUAGE AS A CONSUMER ISSUE

U ntil comparatively recently, the Welsh

language, its importance and its future, were
some of the most controversial subjects in
contemporary Wales. The language was something
one was either for or against; something that was
either crucially important to any definition of Welsh
identity, or a relic from the past which divided the
population whilst adding unnecessarily to the cost of
public administration. It has become increasingly
obvious during the last ten years that a sea-change
has occurred in the attitudes of the Welsh towards the
Welsh language. In spite of the best efforts of some of
the language's most zealous supporters, and some of
its harshest detractors to reignite the flames of
political controversy, the "language question" is no
longer the hot potato it was for so many years. The
NOP survey conducted on behalf of the Welsh
Language Board in March 1995 showed that 77% of
people questioned regarded the Welsh language as "an
asset to Wales", with 88% seeing the language as
"something to be proud of". It is clear by now that a
broad consensus has developed, amongst Welsh
speakers and non-Welsh speakers, in favour of the
continued promotion of the language. It is vitally
important for the future of the language and for the
development of services provided through the medium
of Welsh that this consensus is maintained, and a
feeling is promoted amongst all people in Wales that
Welsh is something that they can feel they have a
stake in and take a pride in, whether they speak the
language or not.

In this new, non-political, context it is particularly
helpful and relevant to look at issues relating to the
Welsh language from a consumerist viewpoint. By
considering accommodation of language choice as
simply part of a quality service to consumers,
questions regarding Welsh-language provision can be
removed completely from the cockpit of partisan
bickering, and disentangled entirely from any
arguments about nationality and definitions of
Welshness. As Dr Dafydd Huws has noted, there are
four main possible reasons for providing a service in
Welsh:

(i) for the sake of the language

(ii) for the sake of the principle involved

(iii) for the sake of the service provider

(iv) for the sake of the consumer
(Roberts, G., 1997)

From a consumerist standpoint, the fourth and only
the fourth of these reasons carries any real weight or
relevance. The aim of Welsh language provision is
neither to secure the future of the language, nor to

uphold the principle of bilingualism, nor to ease the
work of service providers; rather, it is to ensure
appropriate provision for Welsh speaking consumers.

The Welsh Consumer Council standpoint on the Welsh
language is outlined in the two documents Consumers
and the Welsh Language (Welsh Consumer Council,
1993) and Welsh as a Consumer Issue (Welsh
Consumer Council, 1996). In the first of these two, a
neat summary of the Council's standpoint is provided:

"In Wales, language is often seen as a political
and cultural issue. That is, language is seen in
the context of the status, history, rights and
desires, and identity of groups of people. But
one can also consider language as a consumer
issue. That is, one can consider it in terms of
choice, accessibility, and fairness to the
individual." (Welsh Consumer Council, 1993)

At present, any attempt to use Welsh whilst accessing
many services is likely to lead to one of two things:

(i) either discomfort, embarrassment and a frantic
search for the member of staff who deals with
such matters;

(ii) or at worst a personal confrontation between the
service provider and the individual consumer.

Such experiences can only serve to reinforce the
traditional tendency amongst many bilingual speakers
in Wales to keep their Welsh exclusively for use with
friends and family, and to turn to English in public
and/or official situations. This problem is by no
means unique to Wales, and has received some
attention in Catalonia, another bilingual region with a
history of linguistic tension and confrontation. In a
recent policy document published by the regional
government of Catalonia on the Catalan language, it
is described how some people are unwilling to use
Catalan when dealing with public bodies as they
cannot be sure the language will be understood. On
the other hand, if they use Spanish they can be sure
they will be understood and will not be obliged to
switch language or "establish a sort of below-the-
surface argument with the civil servant attending him
or her, an argument that is explicitly expressed
through disfunctions in the interaction." (Generalitat
de Catalunya, 1995).

As noted above, accessibility, choice and fairness to
the individual is the context in this report within
which is assessed the importance of any Welsh
language provision. This same idea of accessibility
and choice is incorporated in the Welsh Language
Board guidelines for the preparation of statutory
Welsh Language Schemes:

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

11

Chapter 3- The Welsh Language As A Consumer Issue

"It should no longer be the case that Welsh
speakers have to press for a service in Welsh...

A request to use Welsh should become no more
than making a choice."

(Welsh Language Board, 1996)

In order for such a choice to be a genuine and
realistic one, it must be one which is straightforward
and convenient for every consumer, including those
who are perhaps least able to express that choice
clearly and confidently. The most eloquent and
confident of consumers are unlikely to demand
services in Welsh if they fear that doing so will lead
to their being labelled as difficult customers, or that
they will have to wait longer or receive a poorer
quality of service because it is in Welsh. This, of
course, is even more true in the case of consumers
who are already lacking in confidence or in a
vulnerable state. To a certain extent, we are all
vulnerable consumers when we present ourselves at a
doctor's surgery or a hospital since we are seeking
help with an injury or illness, often to discuss quite
sensitive and personal matters. Very few consumers
are likely to feel able to demand their rights in such a
situation, however confident they normally are. In
addition to this, four key groups of health care
consumers who are perhaps particularly vulnerable
were identified during research, with that
vulnerability being an ongoing condition. The four
groups identified are:

(i) people with mental health problems

(ii) people with learning disabilities and other
special needs

(iii) the elderly

(iv) young children

Patients from these four groups are often the least
capable of demanding their right to communicate in
their chosen language, but they are often amongst
those with the greatest need to do so. In Section 7.2
of this report, particular consideration is given to the
needs of these four groups. What is being done to
meet the needs of the Welsh speakers amongst them,
and what could be done to better provide for them.

12

WELSHIN THE HEALTH SERVICE

Chapter 4 - THE WIDER CONTEXT - MULTILINGUALISM
IN WALES AND THE WORLD

4.1 Bilingual Wales in a Multilingual Europe

The English language is all around us, and forms a
daily part of almost all of our lives. Through the
medium of a lively and attractive Anglo-American
culture, English has risen from its humble beginnings
to become a popular and powerful language, spread
throughout the world by mass-communication media.
As a result of this, largely unchallenged, supremacy
there is a common tendency in the British Isles and
other regions where English dominates, to see English
speaking monolingualism as an unchanging norm.
Along with this, a basic misconception has grown up
among some English monoglots that bilingualism, or
multilingualism, are uncommon and unnecessarily
troublesome conditions. The reality is a little different,
as the facts below demonstrate:

• It is estimated that 60-70% of the world's
population live and work in two or more
languages in their daily lives.

• Within the European Union (EU) of which the
United Kingdom is an integral part, around

50 million people use a language in their daily
lives which is not the official language of the
country they reside in.

• In Spain, although Castilian (the language
normally referred to as "Spanish") is the main
state language, around 5 million people are able to
speak Catalan and a substantial number speak
Galician or Basque.

• Of all the countries of the EU, only Portugal has
no territorial linguistic minority.

In light of these facts, Wales' bilingual situation does
not appear half as unusual as it does when looked at
from the point of view of English monolingualism as
a norm. From this European standpoint, we are able
to acknowledge the bilingualism of Wales as a wholly
normal and natural situation to be accepted and
welcomed, rather than as a problem to be wrestled
with. And by acknowledging multilingualism as a
norm, we can go on to counteract the effects of
traditional misunderstandings about the nature of the
mind of the bilingual speaker and the importance of
his/her two languages in his/her thought processes:

"There is a danger of treating the Welsh speaker as
somehow two persons in one - a kind of oddity.
Fundamental misconceptions can be avoided by
understanding how knowledge of two languages
can be controlled within a single complete and
integrated person. Regarding one of the languages
as a nuisance factor is incompatible with treating
the client as an integrated and complete whole.

Flence it is crucial that institutional and statutory
frameworks recognise both languages as
necessary and their use as a perfectly normal part
of professional activity."

(Beilin W. in Fluws Williams, Rh„ Williams,

FI. & Davies E.,1994)

4.2 Welsh Wales and English Wales

4.2.1 "Welsh speaking" and "non-Welsh speaking"
Regions - Exploding the Myth

A common, but misleading, assumption is the one
that there are in Wales such things as "Welsh
speaking" and "non-Welsh speaking" areas. This
assumption is incorrect and unhelpful in three main
ways:

(i) It depends on a faulty logic which equates a
numerical scarcity of Welsh speakers or a low
percentage of them in the population with their
complete absence.

(ii) It is based on old-fashioned and prejudiced ideas
regarding the nature and extent of the
geographical territory of the Welsh language:
ideas which were never genuinely valid, and
which are becoming increasingly meaningless
each day. The commonest of these ideas is the
belief that Welsh is the language solely of the
elderly, rural dwellers, and of the north and
west of Wales.

(iii) In the context of service provision, such
assumptions can lead to a belief that the
particular needs of Welsh speaking consumers
can be ignored when planning services in some
areas.

A brief look at the figures from the last Census,
carried out in 1991, is sufficient to explode the myth
that the Welsh language is confined to any particular
part of Wales. In 1991,18.6% of the Welsh population
were recorded as being able to speak Welsh (508,098
people out of a total population of people over 3
years old of 2,723,623). Superficially at least, the
figures do seem to confirm the belief that Welsh is
mainly the language of rural north and west Wales -
55.7% of the 18.6% were to be found in the former
counties of Dyfed and Gwynedd - but one has to look
at the figures with greater care and in greater depth
to see the true picture. By counting numerical totals
of people in particular areas, one finds a rather
different picture from the oversimplified one found by
looking at percentages of the population. For
example, although only 6.6% of the residents of

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

13

Chapter 4 - The Wider Context - Multilingualism I n Wales And The World

Cardiff are Welsh speaking, this small percentage of
the population of the Capital actually adds up to
around 18,000 people, ten times as many Welsh
speakers as are to found in Caernarfon. Taken
together, there are more Welsh speakers in Cardiff and
Swansea (47,637) than in the whole of Anglesey
(41,240). Even in the former county of Gwent, where
the Welsh language is traditionally at its weakest,
10,339 people were recorded as being Welsh speakers
in 1991, and Census counters did not find a single
electoral ward which could be genuinely described as
being entirely "non-Welsh speaking". Wyesham and
St. Mary's (now in Monmouthshire) were the two least
Welsh speaking wards in Wales, accounting for
14 Welsh speakers each (0.8% of the population of the
two wards taken together).

On top of this, a further factor which should not be
ignored is the unsettled and changing nature of the
Welsh language's territory, as population patterns
change and as attitudes to the language change also.

If it was ever true that Welsh was the language of the
rural north and west, that claim can certainly no
longer be sustained. It is in the towns of the south¬
east that the growth of the language is to be seen at
its most striking, in the form of flourishing Welsh
medium schools and the continued growth of
movements like the Urdd; and in the form of a
considerably improved visible presence for Welsh in
shops, offices and other public places. J ohn Aitchison
and Harold Carter's analysis of Census figures from
the turn of the century up to 1991 has shows that the
concept of a Bro Gymraeg or Welsh Gaeltacht as a
bastion of Welshness in the middle of a sea of
Anglicisation is increasingly irrelevant:

"Past censuses have all drawn attention to the
gradual break up of a once discrete and distinctive
core area (Y Fro Gymraeg).... The decline in the
heartland has a reciprocal in the resurgence that
has been identified in the areas lying outside it."

These changes and the effects they are having were
acknowledged in the introduction to the Welsh
Language Scheme published in March 1998 by Gwent
Health Authority, which serves an area where barely
2% of the population speak Welsh at present:

"We recognise that there is a growing interest in
Welsh in Gwent and that Welsh language schools
are flourishing in some of the most anglicised
areas. A new generation of Welsh speakers might
assert their right to relate to the local NHS
through the medium of Welsh. M any more might
already do so if they were confident their query
could be dealt with successfully in the language."

It appears, therefore that there is a need for a serious
reconsideration of conventional ideas about the
territory of the Welsh language. Users of the language
are increasingly likely to be urban dwellers, to be
young people, and to be speakers who have acquired
the language outside of the home. To many such
Welsh speakers, Welsh is a "second language" in as
much as Welsh, in chronological terms, was the
second language they learnt. But the meaning of the
term "second language" should not be extended to
infer that Welsh is somehow a secondary or second-
rate language to them, or that it is any less central to
their identity or a medium in which they are any less
capable in than Welsh speakers who learned Welsh as
their mother-tongue.

These changes are leading to the forming of new
types of social networks which are very different from
the old monoglot Welsh villages - urban networks of
speakers living in an environment where Welsh will
never be the main language of society:

"Towns are cosmopolitan places where Welsh is
inevitably brought face to face with English. It
follows that it is much more difficult to live a life
wholly Welsh in an urban area, and the larger the
town the more difficult it is, regardless of the
number of Welsh speakers."

(Aitchison & Carter, 1994).

It is more relevant and more helpful these days to
think of Welsh speaking individuals and families in
the community, rather than to think of Welsh
speaking communities. Apart from a few single
villages, there are very few places in Wales where the
community is thoroughly Welsh speaking. In many
places Welsh speaking individuals and families are
scattered across wide geographical areas, connected to
each other by organised personal networks rather
than traditional community networks. Some
individual Welsh speakers may be quite isolated from
each other and not a part of any genuine Welsh
speaking society, and yet still be keen to access
service through the medium of Welsh. This is
particularly relevant when those who live in places
such as Wyesham and St. Mary's, Monmouthshire,
and unless we wish to say that the interests of the
28 of Welsh speakers in those two wards are
unimportant, we cannot justify disregarding them by
labelling these areas as "non-Welsh speaking".

In addition to this, it should be remembered that it is
as individuals that patients approach the National
Health Service for treatment, rather than as
representatives of communities, and the needs and
wishes of each individual patient are equally
important. From this viewpoint, the linguistic

WELSH IN THE HEALTHSERVICE:

Chapter 4 - The Wider Context - Multilingualism I n Wales And The World

"Welshness" or otherwise of the region a patient is
living in is wholly irrelevant when considering where
provision should be made for him or her through the
medium of Welsh. The point was acknowledged in the
1975 Welsh Office Circular on the Welsh Language in
the National Health Service (see Section 6.2):

"Relationships between those seeking and those
providing service in Wales can often be assisted
by recognising the importance of the Welsh
language to those whose first language it is. This
is self-evident in predominately Welsh speaking
areas, and applies equally to many individuals
living in English speaking areas."

The same point was acknowledged in connection with
questions regarding provision of minority languages
other than Welsh in the NHS Ethnic Health Unit's
publication, Ethnicity and Health in England. In this
booklet reference is made to the dangers of assuming
that ethnic minority populations are only to be found
in certain areas. By thinking like this, as happens in
the case of Welsh, the needs of small minority
populations may be ignored or neglected simply
because their presence is not sufficiently obvious to
provoke service providers to organise and plan to
accommodate their needs:

"The issue is important not just for health
authorities with large black and minority ethnic
populations, but also for authorities where the
numbers are smaller and hence there is a risk that
their needs will be overlooked. Relatively small
minority ethnic populations can be the most
isolated and disadvantaged in terms of access to
health care." (Balarajan & Raleigh, 1995)

In interviews with health care staff, a working nurse,
a retired former nurse and a hospital social worker all
described their experiences of discovering the "hidden
Welsh" in regions which are generally counted as
being "non-Welsh speaking". All three spoke of the
gratitude and appreciation of these people when they
realised that a member of staff could communicate
with them in their first language. This is the
description given by the retired nurse of his
experiences of coming across Welsh speakers after
moving to work in a traditionally "non-Welsh
speaking" area:

'"Oedd llai o bobl, unigolion o dro i dro. 'Oedden
nhw'n dod o'r pentrefi, yn enwedig yr
hynafgwyr... 0! o'n nhw'n falch bod nhw'n gal Iu
cael cwrdd a rhywun oedd yn siarad Cymraeg.
Achos, yn fewnol, yn wreiddiol, Cymry o'n nhw."

"There were less people, individuals from time to
time. They came from the villages, especially the

old people... Oh! they were so glad they could be
with someone who spoke Welsh to them. Because,
internally, originally, Welsh was what they were."

On a more serious level, the working nurse described
how she was called upon to calm down an elderly
man who was trying to pull a drainage tube from his
nose. All attempts to persuade him in English to leave
the tube alone had failed, but by speaking to him in
Welsh the nurse was able to quieten his anxieties and
explain to him what the tube was for and why he had
to leave it in his nose. It appears that it was entirely
accidental that a Welsh speaking nurse happened to
be in the same part of the hospital as the patient, and
that there was no specific system for dealing with
crises such as this one when they arose. "Oh, that
foreign language," was the response of another nurse
after the situation had been diffused.

Even more serious is the evidence given by the
hospital social worker, as it suggests the linguistic
needs of at least one elderly and confused Welsh
speaking patient have been deliberately ignored and
disregarded after care staff came to know of them.
Whilst visiting the patient in her home to assess her
after-care needs, the social worker noted that she was
unwilling to communicate, and sat silently on her
own. Another visitor happened to be in the house at
the time, and he began chatting with the social
worker, asking her in English where she came from
and then whether she spoke Welsh. The social worker
responded to the second of these two questions in
Welsh, replying, "Ydw, wi'n siarad Cymraeg," ("Yes, I
speak Welsh") producing an immediate response from
the patient who began talking enthusiastically in
Welsh. Apart from some members of her family who
came to see her occasionally, the social worker was
the only person who had spoken Welsh to the patient
for some time. "Oh, that does happen sometimes," was
the only response of her colleagues to the social
worker's report of the incident, and as far as she
knew nothing was done afterwards to meet the
patient's communicational needs.

The simple truth is that there is not, and never has
been, such a thing as a "non-Welsh speaking" area in
Wales, and such old-fashioned ideas about the
geographical territory of the Welsh language can only
stand in the way of any attempts to increase and
develop the provision of services through Welsh.

Welsh speakers are to be found in all parts of Wales,
and it is in some of the most Anglicised areas that the
greatest growth of the Welsh language is to be found.
There is therefore no point attempting to justify
restricting Welsh language provision to certain parts
of Wales. In accordance with its basic principles, the

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

Chapter 4 - The Wider Context - Multilingualism I n Wales And The World

Welsh Consumer Council supports an all-Wales
attitude towards the provision of services in Welsh,
respecting the rights and choices of consumers in
every part of the country.

One other factor to which attention needs to be drawn
is the fact that doctors' surgeries and hospitals,
especially major hospitals, in comparatively "non-
Welsh speaking" towns and cities often serve wider
catchment areas where the use of Welsh is a great
deal more common. The University of Wales Hospital,
Cardiff, is the most obvious example of this, since, as
a specialist centre for a number of treatments, it
provides service to patients from all parts of Wales.
This means that in addition to acknowledging the
linguistic needs of their local catchment areas, the
University Hospital and other similar institutions have
to recognise linguistic patterns over far wider areas,
which may be very different from the patterns found
locally. This point was raised in the 1975 Welsh Office
Circular on the Welsh language in the National Health
Service (see Section 6.2):

"With the increasing development of specialist
services at selected hospitals there are few major
hospitals in Wales which do not treat some
patients who will be put more at ease by a
conversation in Welsh or by listening to Welsh
radio or television programmes."

4.2.2 Low Expectations

The effects of traditional assumptions about which
parts of Wales Welsh is spoken in can be seen in the
form of deeply rooted ideas about in which parts of
the country one can and should expect to receive
services through the medium of Welsh. Very broadly,
the country is divided into north and west where one
should expect Welsh language provision, and south
and east where such provision should not be
expected. The pattern seen consistently in interviews
was that consumers living in areas identified in the
popular mindset as being "non-Welsh speaking" had
very low expectations as regards how much assistance
they could get from the National Health Service in
their chosen language. As a rule, consumers living in
such areas have long since grown used to receiving
services in English only, and are superficially satisfied
with that. However, the evidence collected from
interviews suggests that this tendency to accept
services in English sometimes hides deeper desires for
better Welsh language provision. For example, after
stating very definitely that it would make no
difference to him whether he was treated by a doctor
who spoke Welsh or not, one patient from the south¬
east said without any prompting that perhaps he
would feel differently if he were living further west.

Similar sentiments were expressed by another person
who had recently moved from mid Wales to the
south-east:

"Efallai lie 'ron i'n byw o'r blaen baswn i wedi
creu mwy o stwr a mynnu gweld rhywun oedd yn
siarad Cymraeg. Ond fan hyn, mae'n wahanol -
Saesneg yw iaith y lie a dych chi yst yn arfer a
fe."

("Maybe where I was living before I would have
made more of a fuss and insisted on seeing
someone who spoke Welsh. But down here it's
different - the language of the place is English
and you just get used to it.")

The comments of these two health care users were
reinforced by a member of staff in a large hospital in
the south-east who had recently moved from west
Wales.

"Wi'n gwybod pan fi'n mynd yn 61 at gartref, wi'n
siwr byddai feyn wahanol gartref am ryw reswm...
Wi'n credu achos bo' fi yn [yr ardal hon] wi yn
tueddu i fod mwy Seisnigaidd mewn ffordd, ond
unwaith wi'n mynd gartre mae popeth yn troi."

("I know that when I go home, I'm sure it would
be different at home for some reason... I think
because I'm in [this area] I tend to be more
English in a way, but as soon as I go home
everything changes.")

If the expectations of Welsh speaking consumers in
some areas are very low, it appears that the
expectations of many health care providers as regards
how many Welsh speakers they are likely to be
dealing with are even lower. In interviews with
consumers, several cases were reported where health
care providers had attempted to justify a lack of
provision for Welsh speaking consumers by arguing
that there were no Welsh speakers living in the area.
One woman spoke of how her enquiry about getting a
Welsh speaking health visitor for her child was
answered by a member of staff. The worker said that
she knew nothing about such things, adding, "There
aren't many Welsh speakers in [this area]," and this in
a county where more than 15,000 people are able to
speak the language. Another woman who had
recently moved from the north to the south told how
a dentist's receptionist laughed when she enquired
whether the dentist she was registering with could
speak Welsh. To this woman it was a perfectly natural
question about one of the professional skills of the
dentist who would be treating her young children. To
the receptionist it was an utterly ridiculous enquiry,
and her response to it reflected the belief that the
dental surgery was in a "non-Welsh speaking" area,

16

WELSH IN THE HEALTHSERVICE:

Chapter 4 - The Wider Context - Multilingualism I n Wales And The World

although it was in reality in a county with over
10,000 Welsh speakers. Another Welsh speaker had a
similar experience when trying to find a Welsh
speaking GP in an area where the Welsh language is
traditionally weak:

"Pan wyt ti'n mynd o gwmpas ac yn gofyn, maen
nhw bron a chwerthin."

("When you go around asking, they almost laugh
at you.")

Of course, it is very easy for monglot English staff in
these "non-Welsh speaking" regions not to realise
when they come across Welsh speaking patients, and
for those Welsh speaking patients not to find out
which members of staff they are dealing with who
can speak Welsh:

(i) The English language is such a strong norm in
some parts of Wales that speakers of other
languages will not even consider the possibility
of speaking their language with strangers. They
know full well that to do so is to invite
confusion, and possibly even suspicion and
animosity.

(ii) The Welsh speaking Welsh do not have obvious
physical features, such as skin colour or modes
of dress which would distinguish them from the
non-Welsh speaking fellow Welsh. They often do
not either have distinguishing accents or names.

For both these reasons, it is all-important that an
effective system of identifying and recording patients'
choice of language is adopted (see Section 7.1 ■
Identifying a Patient's Chosen Language.)

Interestingly, it became clear during interviews the
most vehement complaints about lack of Welsh
language provision were coming from consumers in
areas where the provision for Welsh speakers within
the Health Service is at its most comprehensive,
namely in Arfon and Llyn. It is the natural strength of
the Welsh language as a social medium in these areas,
rather than any deliberate policy, which largely
accounts for the easy availability of medical
assistance in Welsh there. On the other hand, the
same natural strength produces exceptionally high
levels of expectation regarding how much should be
available in Welsh. Some consumers from the north¬
west complained that a Welsh language service was
not available every time they went to the hospital,
something which Welsh speakers in the south-east
would be unlikely to complain about, seeing it as
entirely usual and to be expected. It is clear, therefore,
that inconsistent experiences in different regions have
led to a great inconsistency of expectations across
Wales.

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

17

Chapter 5 - THE LANGUAGE OF MEDICINE - THE IMPORTANCE

OF GOOD COMMUNICATION

T he success of any medical diagnosis and course
of treatment depends heavily on effective
communication, and on a good relationship
based on sympathy and mutual understanding
between health care providers and consumers, The
patient must be able to explain his or her symptoms
and feelings to the practitioner who is treating him or
her, and that practitioner must be able to understand
and interpret what the patient is saying. As was noted
in the Audit Commission report, What Seems to be
the Matter: Communication Between Hospitals and
Patients, "There are compelling human reasons for
making sure communication with patients works well.
Good communication can transform that patient's
experience of hospital care, lessening the impact of
what may be painful, difficult or anxiety provoking
situations and decisions." (Audit Commission, 1993)

Of course in order to ensure good communication,
there has to be a common language both the service
user and provider can properly understand (unless a
translator is used to intercede between the two
parties). At present in the National Health Service in
Wales, it is the patient who usually bears the
responsibility for making sure that that common
language is arrived at by using English. In her study
of Welsh speaking pregnant women in the Glangwili
Hospital catchment area, Gwenan Thomas described
the guilt that one mother felt that she could not meet
the linguistic needs of her non-Welsh speaking
midwife because she found herself unable to speak
English during labour. One theme which Thomas saw
during her research was that it was the pregnant
women who were expected to be responsible for
speaking a common language that those around them
were comfortable with. (Thomas, G„ 1998)

On the other hand there is plenty of evidence to
indicate the sort of improvement that can be achieved
when the responsibility for finding a common
language is removed from the shoulders of health
care users and the onus placed instead on providers.
This matter was raised in the 1975 Welsh Office
Circular on the Welsh language in the National Health
Service:

"In a personal service concerned with the health of
patients, the relationship between the service and
individuals seeking advice or treatment must be
close and intimate. M uch depends on the
establishment of confidence between those
administering the service and those who seek it. In
this, the skill and devotion of those who provide
the service is paramount. However, relationships
between those seeking and those providing the
service in Wales can often be assisted by

recognising the importance of the Welsh language
to those whose first language it is...The evidence
received by the Welsh Hospitals Board's Working
Party convinced it of the value to the sick person
of being able to use one's mother tongue in what
can be perhaps a most disturbing and emotionally
fraught situation." (Welsh Office, 1975)

This is supported by the conclusions of Gwerfyl
Roberts after studying communication between nurses
and patients in a large hospital in a traditionally
Welsh speaking area:

"Since the essence of nursing is the development
of a close theraputic relationship between nurse
and patient, the use of the client's native language
can only enhance this relationship and the
consequent quality of care that a patient receives."
(Roberts, G„ 1994)

During interviews, many patients said that they felt
"mwy cartrefol" ("more homely / more at home") if
their health care was provided in Welsh, and it was
remarkable how many people used those exact same
words - "mwy cartrefol" - to describe their feeling
towards Welsh speaking staff. Both Gwerfyl Roberts
and Gwenan Thomas have noted in their research this
tendency to describe care provided through the
medium of Welsh, and the staff who provide it, as
"cartrefol" ("homely"). (Roberts, G,, 1994) (Thomas, G.,
1998) Set out below is a selection of some of the
comments made in interviews by Welsh speakers and
their families regarding the importance of the Welsh
language to them in the context of health care:

"'Os basa 'na ddoctor yn Gymro, baswn i'n gallu
bod yn reit agos ato fo."

("If the doctor could speak Welsh, I would be able
to feel quite close to him".)

"'On i mor falch jyst i glywed rhywun yn siarad
Cymraeg. Wna i byth anghofio hynny."

("I was just so glad to hear someone speaking
Welsh, I'll never forget that.")

"'Oedd un menyw [yn gweithio yn yr hospital]
oedd yn Gymraeg, cleaner. 'Oedd hi'n gret, o'ch
chi'n teimlo mwy cartrefol."

("There was one woman [working in the hospital]
who spoke Welsh, a cleaner. She was great, you
felt more at home with her.")

"Byddwn i'n fwy cyffyrddus 'sen ni'n gal lu siarad
Cymraeg 'da'n gilydd. Mae 'na ryw agosatrwydd
sy'n gwbl wahanol pan wyt ti yn dy iaith gyntaf."
("I would be more comfortable if we could speak
Welsh to each other. There's a certain intimacy
which is totally different in your first language.")

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WELSH IN THE HEALTH SERVICE:

Chapter 5 - The Language of Medicine - The Importance Of Good Communication

"Mae'n bwysig i mi pan dw i'n sal gael y
Gymraeg, mae'n cysuro chi'n well yn eich
mamiaith, tydi? Pan o'n i yn yr ysbyty tro
diwethaf, buodd dau [aelod o staff] yna yn gallu
Cymraeg a phan on i'n wael iawn un nos 'oeddan
nhw ar y gwasanaeth. 0, wyddoch chi beth, 'oedd
yn braf cael bod yn eu cwmni nhw...' On i'n
teimlo'n saff efo nhw, yn Gymraeg!."

("It's important to me when I'm ill to get help in
Welsh, you feel more reassured in "your" mother-
tongue, don't you? Last time I was in Hospital
there were two [members of staff] there who could
speak Welsh and when I was very ill one night
they were on duty. And you know, it was lovely to
be in their company... I felt safe with them, in
Welsh!")

"'Oedd e'n licio'r nyrsys oedd yn siarad Cymraeg...'
Oedd e'n closio atyn nhw. 'Oedd e'n gal Iu ymlacio
efo nhw."

("He liked the nurses who spoke Welsh... He
became quite close to them. He could relax with
them.")

On the other hand, a number of patients described
how a communication gap opened between them and
medical staff because they were not given the
opportunity to express themselves in Welsh as they
wished to do:

"Wi'n ffaelu explaino i'r doctoriaid beth sy'n bod
arna i yn Saesneg."

("I can't explain to the doctors what's wrong with
me in English.")

"Pan ych chi'n gweud beth ych chi eisiau a pwy
siort o help ych chi eisiau, mae'n rhwyddach i mi
wneud e'n Gymraeg."

("When you are saying what you want and what
sort of help you want, it's easier for me to do it in
Welsh.")

"Mae hi gymaint haws i siarad yn Gymraeg efo'ch
problemau chi. Yn y Gymraeg mae gynnoch chi
ddiffiniadau o wahanol fathau o boen, a does
gynnoch chi ddim, a dweud y gwir, yn Saesneg
sy'n naturiol, oni bai eich bod chi'n Sais naturiol."
("It's so much easier to speak Welsh when
discussing your problems. In Welsh you've got
definitions of different sorts of pain, which you
won't have naturally in English, unless you are a
natural English speaker.")

In the same way, one woman described her experience
while visiting an elderly relative of hers in hospital:

"Daeth yr arbenigwr efo'i haid o feddygon ifanc
yn gofyn cwestiynau iddi hi, ac roedd hi'n ateb
pethau'n anghywir. Wedyn dwedodd hi, "On i
ddim deall gair oedd o'n ddeud.""

("The specialist came round with his flock of
young doctors, asking her questions, and she was
answering them wrongly. Afterwards she said, "I
didn't understand a word he said."")

A similar picture to that presented by patients was to
be found when talking to bilingual health care
workers about the importance of Welsh in their work.
Here, for example, are the comments of one
experienced nurse:

"Mae rhai pethau allwch byth a chyfieithu. Allwch
byth a chyfi eithu teimladau pobl... Ych chi'n
gwybod beth ych chi'n feddwl yn eich iaith eich
hunan."

("There are some things you can never translate.
You can never translate people's feelings... You
know what you mean in your own language.")

Two other nurses went so far as to claim that they
had been able to make better diagnoses by being able
to communicate with patients in their first language:

"A deud y gwir, dach chi'n cael mwy o wybodaeth
ganddyn nhw, y rheini sy'n siarad Cymraeg. Maen
nhw'n agor eu hunan alIan yn fwy yn Gymraeg."
("To tell you the truth, you get more information
from the one's who speak Welsh. They open up
more in Welsh.")

"Wi'n gwybod o acen y claf fod e'n siarad
Cymraeg, a wi'n gweud, "Ych chi'n siarad
Cymraeg?" a maen nhw'n gweud "0, ydw, "a wi'n
cael cymaint mwy o wybodaeth allan o'r claf pan
wi'n gweud 'na.""

("I know from a patient's accent whether he
speaks Welsh, and I'll ask, "Do you speak Welsh?"
and I get so much more information out of the
patient when I ask them that.")

The obvious implication of the remarks is that if
bilingual staff are able to get better information from
Welsh speaking patients, then non-Welsh speaking
staff are unable to obtain such good information from
the patients on account of the communication gap
between them. Some Welsh speaking patients are
therefore not receiving as good a service from the
National Health Service as they should, because the
Health Service does not provide them with an
opportunity to describe their condition in their first
language. This goes along with the comments of
Neil Wooding of the NHS Wales Equality Unit at the
launch in December 1998 of the Unit's report on
health care provision for minorities in Wales:

"To communicate service through one language
only could deny the chance to some people whose
first language is not English to get proper access
to health care." (Turner, R„ 1998)

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

19

Chapter 5 - The Language of Medicine - The Importance Of Good Communication

One other thing that became clear during interviews
was that there are two main factors which are likely
to increase the importance of language choice in the
minds of Welsh speaking patients and their families:

(i) If the period of any illness is an extended one
requiring long-term care. For example, in the
case of cancers or other ongoing illnesses.

(ii) If discussion and counselling are an important
part of any treatment provided.

This point is particularly relevant to the field of
mental health care and psychiatry, where talking is a
major part of any treatment (see Section 7.2.1 -
Mental Health). There are also other kinds of
treatment, particularly those which are particularly
severe or painful, which require considerable
discussion between consumer and provider, and may
require considerable professional counselling if the
patient is to come to terms with the nature and effects
of the treatment. In connection with this, it is
interesting to note the comments of one woman who
had undergone severe surgery on her face:

"Wnaiff [iaith] ddim gwahaniaeth i fi. Saeson
dw i 'di cael yn consultants ar hyd yr adeg. Ond
wedi dweud hynny, 'on i'n dod i weld y meddyg
i lawr yn fan hyn wedyn, fy meddyg i fy hun,
ac 'oedd hi'n braf cael siarad yn Gymraeg efo
fo. Mewn ffordd, 'oedd o'n helpu siarad yn y
Gymraeg. Y counselling oedd yn braf yn
Gymraeg."

("Language makes no difference to me. I had an
English speaking consultant right through. But
after saying that, afterwards I started going to
see the doctor here, and it was good to be able
to speak Welsh with him. In a way it helped to
be able to talk in Welsh. It was the counselling
that was good in Welsh.")

20

WELSH IN THE HEALTHSERVICE

Chapter 6 ■ BASIC PRINCIPLES

6.1 CCETSW's Five Principles

In 1994, Elaine Davies on behalf of CCETSW (Central
Council for Education and Training in Social Work)
set out five principles regarding language choice for
social workers in Wales:

" • A client has the right to choose which
language to use with a worker.

• Language is an essential part of a person's
identity.

• A person can express feelings more effectively
in a chosen language.

• Giving a client real choice regarding use of
language is the essence of good practice.

• Denying this right is a way of oppressing a
client."

(Davies, E., 1994)

These principles originated from some of CCETSW's
deep-seated anxieties at the way Welsh speakers were
being disadvantaged by services which were planned
with no regard for language choice as a significant
factor. CCETSW as an institution was very much
ahead of the pack in the field of raising language
awareness as an important issue when dealing with
vulnerable clients, and a number of CCETSW
publications on the subject were referred to when
preparing this report.

6.2 1975 Welsh Office Circular on the Welsh
Language in the National Health Service in
Wales

This Circular was published in March 1975 by the
Health and Social Work Department of the Welsh
Office under the full title Welsh Health Service
Circular (Interim Series) The Health Service and the
Welsh Language. It is particularly interesting as one of
the first official documents to look specifically at the
importance of language choice in the context of
health care. Published some 18 years before the 1993
Welsh Language Act, the Circular includes a number
of key points which were later included in the Welsh
Language Schemes which came in the wake of the
Act. Although copies of the Circular were sent when it
was published to every Health Authority, Family
Practitioner Committee, County Council, District
Council, and Community Health Council in Wales,
and also to the Welsh Health Technical Services
Organisation, it is very difficult to find any firm
evidence as to what effect the document had on
attitudes to Welsh language provision at the time. It
appears unlikely that the Welsh Office did any follow¬

up monitoring work. The principles of the 1975
Circular are as valid today as they were when it was
published and reference is made to a number of the
points raised in the Circular in various places in this
report, where relevant and appropriate.

6.3 The Patient's Charter, a Charter for Patients
in Wales 1996

The Charter states:

"You can expect the following...

• To be given information, as far as possible in
English and Welsh."

This is confirmed in The Patient's Charter - Services
for Children and Young People in Wales:

"Your doctor, nurse or health visitor will explain
any treatment, as far as possible in English and
Welsh.

6.4 1998 White Paper on the National Health
Service in Wales/ Putting Patients First

This White Paper on the National Health Service in
Wales was presented to Parliament in J anuary 1998.
Although there is no specific mention in it of
language choice or Welsh language provision, it does
raise a number of points which are relevant to any
discussion of the Welsh language and health care. In
the same way as the report Changing Childbirth,
published by the Department of Health in 1993,
Putting Patients First foresees a National Health
Service where the unique personal needs and wishes
of individual patients are increasingly placed at the
top of any list of priorities when planning and
providing health care. "Patient-centred care" is the
new motto, as can be seen from this piece from the
white paper:

"Services should be designed around the patient so
that, consistent with other values, the NHS
delivers the quality of treatment and care that
patients and carers need, in the way they want it."

And further on in the document, under the heading
Defining Quality:

"Increasingly user-orientated definitions [of
quality of health care] have been applied which
also recognise the importance of people's needs
and expectations... Patients want to be seen
quickly in conditions which respect their privacy
and dignity and to be cared for by staff who
understand their needs and concerns as
individuals."

21

Chapter 6- Basic Principles

From the standpoint of the Welsh Consumer Council,
this commitment to tailor services to suit consumers'
needs and wishes is to be warmly welcomed. Our
argument now would be that, in order to be relevant
to contemporary Wales, this commitment has to
include within it a commitment to expand definitions
of quality of service to include language choice.

The White Paper also looks at the quality and
adequacy of information given to patients regarding
their condition and their treatment:

"If patients are going to be equal partners in their
health care, they need clear, comprehensive and
personalised information about the risks, benefits
and treatment options for their conditions."

As all information, be it verbal or written, depends on
language to be conveyed, if we are serious about
improving the information given to patients we
cannot afford to disregard language as an important
factor. In order for information to be adequate and of
the best possible standard for every patient, it must be
presented as far as possible in the language the
patient best understands. This is particularly relevant
when it comes to discussing sensitive and emotional
matters relating to serious illnesses of the body and
the mind. Note the use of the term "personalised
information" in the above piece from the white paper,
the word "personalised" suggesting something
especially adapted for the individual patient.

6.5 Statutory Welsh Language Schemes

The basic principle of any Welsh language provision
are laid out in the Welsh Language Board's handbook,
Welsh Language Schemes - Their Preparation and
Approval in Accordance with the Welsh Language Act
1993, where particular attention is given to the rights
and needs of vulnerable consumers:

" • offering the public in Wales the right to

choose which language to use in their dealings
with the organisation:

• recognising that members of the public can
express their views and needs better in their
preferred language:

These principles are relevant to all public services, but
are particularly appropriate for organisations
providing services to people who are in vulnerable
situations, such as services involving counselling and
care."

(Welsh Language Board, 1996)

• recognising that enabling the public to use
their preferred language is a matter of good
practice, not a concession:

• and that denying them the right to use their
preferred language could place members of the
public at a real disadvantage

22

WELSH IN THE HEALTHSERVICE:

Chapter 7 - DISCUSSION TOPICS

N o research project develops in a vacuum, and
every researcher has his or her own
expectations as regards which subjects are
likely to prove significant as the research goes on.

This project has its origins in a number of anxieties of
the Welsh Language Board and the Welsh Consumer
Council regarding the inadequate nature of the
current provision for Welsh speaking patients, and
from a desire to find out how much basis there is for
those anxieties. Analysis of a number of the subjects
discussed during the confidential interviews with
consumers and staff and/or in the 24 interviews with
key individuals, and/or which came up during the
desk-based research. Some of these subjects are ones
which were expected before the research began to
come up, but the majority of them are subjects to
which the author's attention was drawn during
interviews by consumers and staff.

7.1 Identifying a Patient's Chosen Language

Every Welsh Language Scheme adopted by NHS
Trusts in Wales includes a commitment to establish
each patient's chosen language during the patient's
first contact with the Health Service. It is usually
intended that this will be done by asking GPs to
record language choice and transfer that information
to any NHS Trust when referring the patient. The
evidence collected whilst writing this report strongly
indicates that this is not happening. In the survey
conducted by Beaufort Research in December 1998,
88% of respondents said that they had never been
asked when visiting a doctor's surgery or hospital
whether they would prefer to speak Welsh. Amongst
respondents from one region (the north-east) the
percentage of negative answers rose to 95%. The
same picture was found in the evidence given by
patients and staff in interviews, evidence which
suggests that identifying patient language choice is
continuing to take place in an accidental and ad hoc
fashion, if it is taking place at all. If the picture is a
correct one, then it is a major cause for concern, since
all arrangements for providing Welsh-medium
services are dependent for their effective operation on
one simple action - the identification and recording
of every patient's language choice. Unknown needs
cannot be met; and provision cannot be made for the
Welsh speaking patient who has not been identified as
a Welsh speaker.

In interviews, very few patients could remember being
questioned as to their chosen language by a member
of staff. According to the testimony of both staff and
consumers, both sides will depend almost entirely on
a variety of accidental and unreliable methods to

identify which language any one patient would prefer
to speak. One thing which all these methods have in
common is that they are based to a large extent on
old-fashioned and static ideas about what sort of
people from which sort of areas can speak Welsh:

(i) In traditionally Welsh speaking regions, such as
Dwyfor and Caernarfon, there is a tendency for
staff and patients to assume that Welsh will be
the medium of discussion. As one interviewee
said:

"'On i'n cael y teimlad yn ysbyty [un dref] bo'
nhw'n siarad Cymraeg a chi os on nhw'n
gwybod bo' chi'n siarad Cymraeg neu beidio,"
meddai un person.

("I got the feeling in [one] hospital that they
would speak Welsh to you whether they knew
you were a Welsh speaker or not.")

(ii) In other areas, staff said that they often
depended on hearing patients speaking Welsh
with their families, and a number of patients
said that this was how they thought staff had
identified their chosen language. Although this
method is fairly effective, it does not work in
the case of those who come to the doctor's
surgery or hospital on their own, or who do not
receive visitors whilst staying in hospital. It
should not be forgotten either that 28% of
Welsh speakers either live alone or are the only
people in their household who speak Welsh.

Such people are far less likely than others to be
overheard speaking Welsh to relatives.

(iii) A number of health care users and staff said
that they tend to ask people which language
they speak after asking them where they come
from originally. If the other person originates
from a traditionally "Welsh speaking" area, one
can then move on to ask whether he or she
speaks Welsh. The flaws in this method become
obvious when one remembers that around half
of Welsh speakers live in areas which are
traditionally regarded as being "non-Welsh
speaking".

(iv) Staff may also depend on such things as accent
and the way a patient speaks English. As many
non-Welsh speaking people from Wales have
strong Welsh accents, and many Welsh speakers
speak English with little trace of a regional
accent, this method is not particularly reliable.

(v) Some staff look to see if a patient has a
particularly Welsh name. Although this
sometimes works, it cannot be relied on. It is
common enough these days for non-Welsh

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23

Chapter 7- Discussion Topics

speaking parents to give their children
traditional Welsh names, whilst many native
Welsh speakers have very English-sounding
names.

(vi) Gwenan Thomas' research revealed that some
people believe they can spot whether other
people are "Welsh-looking" or "English-
looking", although no one could explain exactly
how this worked. As one women interviewed
said:

"Sain gw'bod beth sy'n wahanol, ond ti'n edrych
[ar rywun] a meddwl Saesnes yw honna,"

("I don't know what's different, but you look
[at someone] and think she's English.")

(Thomas, G., 1998)

(vii) Gwenan Thomas has also described the attempts
some of the women she spoke to had made to
reveal the language choice to medical staff and
to change the language of conversation from
English to Welsh by attaching occasional Welsh
words or phrases to English sentences. The
success of this method depended to a large
extent on the sensitivity of staff to what the
women were doing, and if the method did not
prove successful at the first attempt the women
were likely to give up. (Thomas, G., 1998)
Gwerfyl Roberts has also described subconscious
attempts by nurses and patients to change the
language of a conversation by throwing a few
Welsh words into a conversation being
conducted in English. (Roberts, G„ 1994)

(viii)Some staff said that they tried to find out which
school children are attending when they come in
as patients, to see whether it is a Welsh-medium
school: and in the field of speech therapy, it can
be seen from referral forms whether a child is
attending a Welsh-medium school. Although this
method is much more dependable than many
others, it is of little help to Welsh speaking
children who are outside the Welsh-medium
education system.

(ix) One former nurse said that she used to look at
records of patients' religion to see if they
belonged to a Welsh speaking denomination.

Depending on methods like those listed above often
leads to uncertainty and missed opportunities to
communicate in Welsh, as two people testified in
interviews:

"Cawson ni'n cyfeirio gyda'r hwyr at yr ysbyty,
a gweld meddyg. 'Oedd hyn i gyd yn digwydd
yn Saesneg, mi ddarganfyddon ni wedyn fod y
meddyg oeddan ni wedi bod yn siarad efo fo,

'oedd o'n siarad Cymraeg. Ond doeddan ni ddim
yn gwybod hynny tan ar 61. Fallai fod ychydig
bach yn ei acen, ond dydy acen ddim yn arwydd
da bob tro."

("We were referred late at night to the hospital,
where we saw a doctor. All this happened in
English. We discovered later that the doctor we'd
been speaking to did speak Welsh. But we didn't
know until afterwards. Maybe there was
something in his accent, but accent isn't a good
indicator every time.")

"Bues i'n gweld y nyrs 'ma unwaith yr wythnos
am wythnosau, misoedd efallai. I gael treatment.
Sawl tro mi fuodd bron i mi ofyn iddi oedd hi'n
siarad Cymraeg. 'O'n i ddim yn siwr am ei hacen
hi, ond 'oedd hi'n dod o dre ddigon
Cymreigaidd. Eto i gyd, dych chi byth yn
gwybod."

("I was seeing this nurse once a week for weeks,
months maybe, to have treatment. A few times I
almost asked her whether she spoke Welsh. I
wasn't sure about her accent, but she came from
quite a Welsh speaking town. Then again, you
never can tell.")

One thing which became obvious during interviews
was that it was those people who had an inherent
interest in other people, their business and their
personal history, who found it easiest to find out who
spoke Welsh. For people like this, enquiring about the
language of some one they have only just met is
entirely natural, since they already make a habit of
questioning strangers about their backgrounds and
their life stories. A small number of health care
consumers who had rarely if ever had trouble
identifying which staff and patients around them
spoke Welsh, and who had rarely had any problems
using the language afterwards with the Welsh
speakers they had identified. A number of factors
were characteristic of this group of consumers,
namely that they were without exception middle-aged
men who had had some experience of public life, and
who were well used to dealing with a wide range of
people. For example, one interviewee of this sort
stated:

"Yn uniongyrchol, pa fi'n cwrdd a pobl a wi'n
'neud ymdrech mawr i wybod pwy yn nhw, o ble
maen nhw'n dod a beth yw eu hiaith."

("Straight away, when I meet people, I make a
great effort to find out who they are, where
they're from and what their language is.")

For the less confident and less naturally sociable, it's
not so easy. For a number of reasons, patients may be
reluctant to ask the staff treating them whether they
speak Welsh:

24

WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

(i) A feeling that English is the usual language of
the institution. This is especially true of regions
which are traditionally considered as "non-
Welsh speaking", and the feeling is reinforced by
such things as monolingual English signs and
English only greetings by staff.

(ii) A fear of appearing troublesome or being seen
as making a political stand.

(iii) A fear of annoying staff and a desire to please
them. In an interview, one member of medical
staff spoke of how many Welsh speaking
patients do not insist on speaking Welsh even if
the option is available to them, preferring to
leave the choice of language in the hands of the
staff treating them:

"Dydyn nhw ddim eisiau mynd off ar y wrong
foot efo rhywun maen nhw eisiau i helpu nhw."
("They don't want to get off on the wrong foot
with someone they want to help them.")

(iv) A fear of making staff who may be non-Welsh
speaking feel uncomfortable by questioning
them about language. For example, one health
care user said:

"Roedd y therapist yn wych - arbennig o alluog.
'O'n i'n pendroni trwy'r amser trwy'r amser am
ofyn i hi oedd hi'n siarad Cymraeg, achos 'o'n
i'n amau bod hi. Ond 'o'n i'n ofni byddai hi'n
meddwl wedyn bo fi'n credu bod hi ddim yn
ddigon da i fi os oedd hi'n ddi-Gymraeg.
Ddywedais i ddim byd yn y diwedd a fe
wnaethon ni'r cyfan yn Saesneg."

("The therapist was great - very capable. I was
wondering all the time should I ask her if she
spoke Welsh, because I thought she might do.

But I was worried she'd think I though she
wasn't good enough for me if she didn't speak
Welsh. I didn't say anything in the end, and we
did everything in English.")

(v) A fear of being seen as stupid because of the
perceived imperfection of their English.

(vi) A feeling that they should not have to ask
especially for Welsh language provision:

"Pan ych chi'n gofyn Vo you speak Welsh, Ych
chi'n siarad Cymraeg,' ych chi fel 'sech chi yn
teimlo islaw... Ych chi'n teimlo fel 'sech chi'n
gorfod begian."

("When you ask "Do you speak Welsh? Ych
chi'n siarad Cymraeg?" You feel as if you're
somehow below them... You feel as if you're
having to beg.")

At least one NHS Trust is currently introducing a
system to ensure that a sticker noting that a patient
wishes to speak Welsh will be placed on his or her
case notes or medical records. Another Trust is also
considering using stickers like this, in addition to
noting language choice on the plaque above each
hospital bed showing the patient's name, and giving
each patient a bracelet to wear coloured according to
language choice. Understandably, some anxieties have
arisen as to how appropriate it is to label patients in
this manner. In the same way, evidence was heard
that some Welsh speaking staff in one area have
express an unwillingness to wear badges showing that
they speak Welsh. One person even went so far as to
compare such badges with the yellow stars which
J ews were forced to wear in Nazi Germany. Although
such anxieties are very understandable, it has to be
acknowledged that there is an undeniable need for
formal methods of recognising which patients and
which staff are Welsh speaking - for the convenience
of both parties, and most of all for the benefit of
patients. As old social networks break up, and people
move more and more from region to region, it is no
longer sufficient for us to depend on methods of
language identification based on knowing who's who
and where they come from. It is very difficult to see
how Welsh speaking staff and patients can be
expected to be able to identify each other without
some sort of clear visual system of badges and/or
signs and coloured stickers. No such system of noting
patients language choice needs to stigmatize any one
if it is presented as part of a comprehensive system
for noting various individual needs that staff should
know about. For example:

(i) Language choice, be that Welsh, English or any
other language.

(ii) Vegetarian, Kosher, Halal diet etc.

(iii) Standard drugs not to be administered.

Another question which arises naturally from any
consideration of how patients' language choice is
identified is what use is then made of any such
information after it is collected. Even in the
institutions where some effort is made to deliberately
record language choice, it is not clear to what extent
those records are referred to when planning
treatment. The impression one generally gets is that
this also takes place in an ad hoc fashion.
Interestingly, a recent survey by the NHS Wales
Equality Unit and the Commission for Racial Equality
showed that the way in which most health care bodies
make use of staff skills in other minority languages is
just as ad hoc as in the case of Welsh. (NHS Equality
Unit & Commission for Racial Equality, 1998) This

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

25

Chapter 7- Discussion Topics

goes along with the general tendency in many areas
of work to undervalue workers' bilingual skills and to
fail to take full advantage of them.

7.2 Four Key Groups

As noted above, during the research for this report,
four key groups of vulnerable consumers were
identified, and these deserve particular attention:

(i) People with mental health problems: The serious
pain and disturbance which arises from a mental
illness can sometime be worsened if the patient
does not have an opportunity to discuss his or
her feelings and experiences in his or her chosen
language. Since the aim of any mental health
care is to restore the normal balance of the
mind, the Welsh language (or any other
language) cannot be ignored as a factor if it
forms a significant part of the normal life and
thought processes of any patient.

(ii) People with learning disabilities or other special
needs: The difficulties which face people in this
situation can be intensified if they are obliged to
communicate in their second language. There is
significant anecdotal evidence that Welsh
speakers with learning disabilities do respond
better to stimulus in their first language.

(iii) The elderly: In general, every one of us is likely
to increase our use of health care services as we
get older. Amongst the older generation of NHS
consumers there is a small but significant group
from strongly Welsh speaking areas who never
fully learned English. These people may suffer
genuine distress and confusion when obliged by
illness or frailty to move from their normal
Welsh speaking environment to a medical
institution where English is more generally used.
In addition to this, a number of fully bilingual
Welsh speakers do revert to using only their first
language, particularly after suffering a stroke or
during a period of dementia.

(iv) Young children: Young children are also
frequent Health Service users, and of all NHS
consumers, they are the most likely to be
monolingual Welsh speakers.

These are the same four categories of health care
users described in the 1975 Welsh Office Circular on
the Welsh language in the National Health Service
(see Section 6.2):

"Relationships between those seeking and those
providing the service in Wales can often be
assisted by recognising the importance of the
Welsh language to those whose first language it

is... [This] has particular relevance to certain
groups of patients - the young and the elderly -
who in some cases may have difficulty in
making their wishes known in a second
language - and to the mentally ill and the
mentally handicapped." (Welsh Office, 1975)

7.2.1 Mental Health

Of all the medical fields studied during the research
for this report, it is probable that this is the one where
the need for proper provision in the patient's chosen
language can be most clearly seen. As any treatment
for mental illness involves bringing the patient back
to his or herself and restoring the normal balance of
the mind, it is hard to see how that can be achieved
without first understanding the nature of the norm to
which one is seeking to return. For the patient whose
normality is a Welsh speaking one, treatment in
English will not necessarily be appropriate or helpful.
In an interview, one member of the family of a
mental health care user gave a simple description of
the importance of language to that person:

"Pan fydd e yn ei isymwybod, Cymraeg yw ei
iaith e."

("When he's in his subconscious, Welsh is his
language.")

A similar opinion was to be had from another person
when talking of his own experiences of receiving
health care (see Section 6.2):

"Mae mynegi teimladau yn rhan fawr o'r peth ac
yn Gymraeg 'wytti'n teimlo'n naturiol... Nid
mater o ba mor hawdd ydy i wneud hynny yn
Gymraeg neu Saesneg. Nid mater o ba mor
alluog ydy rhywun yn ieithyddol ydy o - beth
sy'n naturiol, lie y mae'r integrity, lie mae'r
cyflawnder naturiol ydy o mewn gwirionedd."
("Expressing feelings is a big part of it, and in
Welsh you feel more natural... It's not a matter
of how capable some one is linguistically - it's
about what's natural, where your integrity is,
your natural wholeness in fact.")

These points, made by health care consumers, were
reflected by the psychotherapist Dr Dilys Davies in
her assessment of the importance of language in her
work:

"Language is an example of the set of rules
which gives form and meaning to our
experience. Our language is thus an intrinsic
part of our sense of self or personality... If you
speak another language, the way your constructs
are formed and the way you construct yourself
and the world are different because the cultural

26

WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

context in which they are embedded is different.
If psychotherapy is about exploring meaning
systems, there is a need to represent or
symbolise a person's experience not ignore it."
(Davies, D„ unpublished draft)

On the other hand, substantial evidence was found
regarding what can happen when mental health care
providers, for whatever reason, fail to provide for
Welsh speaking patients in their language of choice.

In one case the family of one patient had to be called
into hospital to comfort him as he was rambling in
Welsh and staff were unable to find another Welsh
speaker to talk to him. Another person described his
experience of taking a very unwilling mentally ill
person to hospital. After much discussion, the man
was persuaded to go to hospital but was bitterly
disappointed upon arrival when he was told there
were no staff there at the time who could talk to him
in Welsh. "'Oedd o'n teimlo'n enbyd o ddiymadferth,"
("He felt terribly helpless") was his companion's
description of his reaction to the situation.

A member of the family of one patient went so far as
to claim that he was returning home from periods of
care in hospital severely confused, having been
obliged to use both English and Welsh there even
though he was used to using Welsh all the time. Most
serious of all, was one case where a mentally ill
patient who was either unable or unwilling to speak
any language other than Welsh, was kept for a period
of several weeks in a psychiatric hospital where there
was not one Welsh speaking member of staff
available to talk to him. In this case, the patient's
family were the only people he was able to
communicate with. One nurse described the situation
at the time:

"He can't communicate his feelings to staff... He
is improving but there's not a lot we can do,
because if you think about the role of a
psychiatric nurse, a lot of it is to do with
communciation and it's a bit hard when you
can't communicate."

Evidence was also collected from families about the
way in which some Welsh speaking mental health
care users occasionally insist on speaking English
when discussing their problems. It seems that some
first language Welsh speakers feel that they are able
to de-intensify the situation they are in, and stand
somewhat outside themselves, by turning to their
second language. This was confirmed in interviews
with several patients' family members, who described
how they had refused to speak Welsh at certain times
as a means of distancing themselves from their
families and/or from themselves. One woman

described how her husband would usually discuss his
mental illness in English as he somehow felt more
comfortable discussing something so personal in a
language which was to him essentially an official and
impersonal one.

"Wi'n meddwl fod e'n gosod rhywfaint o bell ter,
rhyw fath o godi wal rhyngoch chi a'r rhai
agosa' atoch chi os dych chi'n defnyddio'r
Saesneg. Yn y Gymraeg ych chi'n hollol eich
hunan, ac mae amddiffynfa lawr on'd yw hi?
Mae Saesneg yn iaith ffurfiol ac allanol."

("I think he was establishing a certain amount of
distance, somehow building a wall between
yourself and those closest to you by speaking
English. In Welsh you are totally yourself, and
all your defences are down, aren't they? English
is an official and external language.")

Credai'r wraig hon hefyd fod teimladau ei gwr ynglyn
a'i salwch wedi'u plethu'n ddyrys a'i deimladau am
iaith:

"'Oedd e'n teimlo'n gryfach yn y Saesneg: 'oedd
e'n teimlo gwendid yn y Gymraeg. Fel on i'n
dweud, 'oedd e'n teimlo fod e wedi cael ei
israddio amser 'oedd e'n blentyn oherwydd [ei
fod yn siarad] y Gymraeg. Ac wedyn... mae
teimlo eich bod chi wedi'ch israddio oherwydd y
salwch, neu'r mae'r salwch yn gysylltiedig a
rhyw deimlad o fod yn waeth na phobl eraill, ac
mae cymhlethdod yr iaith yn creu problemau
eraill... 'Oedd e'n teimlo'n fwy cadarn, yn fwy
siwr o'i hunan mewn sefyllfa mor ofnadw ac
ansicr, yn teimlo bod sgitsoffrenia arnoch chi ac
yn ei ofni. 'Oedd e'n well gyda fe bod yn
Saesneg."

This woman also thought that her husband's feelings
about his illness was also related to his feelings about
language.

"He felt stronger in English, and felt weak in
Welsh. As I said, he felt inferior when he was
young speaking Welsh. And then.... feeling
inferior because of your illness, or worse than
everybody else, and the complication of
language causes further problems... He felt
stronger, and more sure of himself in a terrible
situation, feeling schizophrenic and scared. He
preferred to be English".

However, in every such case looked at, the patient's
family members said that he or she had later returned
to speaking Welsh, and that that change had usually
assisted the treatment process. For example:

"Roedd un nyrs Cymraeg yn [y clinig], a daeth
hwnnw wedyn i'r ty... Dw i'n gwybod bod hynny

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Chapter 7- Discussion Topics

wedi bod yn help mawr iddo fe ail-gydio yn y
feddyginiaeth... 'On i'n gweld [y claf] wedi
ymlacio mwy achos fod e'n Gymraeg... mwy
naturiol."

("There was one Welsh speaking nurse in [the
clinic], and came to the house later on. I know
that that really helped [the patient] to start
taking his tablets again... I could see [the
patient] was more relaxed because the nurse
spoke Welsh... more natural")

As described below in the section looking at speech
and language therapy (see Section 7.3 below), in a
situation like this one, the bilingual worker is an
invaluable asset to the Health Service. In a situation
where a patient, for any reason, is switching between
two languages, it is the bilingualism of the workers,
rather than his or her ability in any one language,
which is the key skill. A bilingual worker can cope
easily with this sort of code switching by a patient,
changing his or her own language according to the
wishes of the patient in a way which would be
impossible for a monoglot worker. The bilingual
worker is also more likely to understand a patient's
need for switching codes at various times, and to
notice the different sorts of subjects the patients
chooses to discuss in the two different languages.

Section 13(2) of the 1983 Mental Health Act stipulates
that if any patient is being assessed to see whether he
or she can be compelled to enter hospital, the patient
should be interviewed by a social worker in a
"suitable manner". This point is reinforced in the Code
of Practice published under Section 118 of the Act. In
Paragraph 2.11 of the Code it is stated that the term
"suitable manner" means that the patient and the
social worker must be able to understand each other's
language. If they do not, the services of a translator
should be called upon, or a social worker who
understands the patients' language should be found to
perform the assessment or to help with it. Although it
is possible to argue that none of this is relevant to
bilingual speakers in Wales since almost all of them
understand English, the question which needs to be
asked in the context of language and mental health
care is what exactly is meant by the word
"understand". If a confused Welsh speaking patient,
on top of all his or her other problems, is obliged to
communicate in his or her second language because
that is the only language of the worker assessing him
or her, it is perfectly reasonable to question if it's
really possible to establish a deep and genuine
understanding between the patient and the assessor.

In this matter, one experienced psychiatrist expressed
his firm opinion that he had come across some

patients he would not have been able to properly
assess if he had not been able to speak Welsh with
them:

"Dw i'n meddwl bod hi'n gwbl annheg ar y
cleifion.... Yn anffodus, y bobl sydd ddim yn
siarad Cymraeg, maen nhw'n tueddu i gredu bod
eu hasesiad nhw yn ddigonol, wel dw i ddim."

("I think it's totally unfair on the patients.
Unfortunately, the people who don't speak
Welsh, tend to believe that their assessment is
adequate, well I don't.")

A number of bilingual mental health care staff did
testify that attitudes to Welsh in the field have
improved during the last 10 years, in traditionally
Welsh speaking regions at least. At the same time,
more and more people are beginning to demand
treatment in Welsh although it still remains difficult
to persuade some Welsh speakers with mental
illnesses to insist upon their right to this. The cruel
irony of this situation is that while mental illness may
intensify the need for help through the medium of
Welsh, at the same time it often deprives the sufferer
of the confidence necessary to demand such help. The
quotation below illustrates the lack of confidence of
one long-term mental health care user, who saw
herself at fault rather than her care provider because
she desired assistance in Welsh but was unable to get
it. This is a classic example of the assumption by
staff, and the acceptance by patients, that it is health
care users rather than providers who should be
responsible for ensuring a common language is used
in any communication:

"Efallai bo' fi' hunanol, ond byddwn i'n
hapusach yn siarad Cymraeg."

("Maybe I'm selfish, but I would be happier
speaking Welsh.")

The same lack of confidence was to be seen in
another interview with a family member of a mental
health care user, who was being kept in hospital for a
prolonged period. "Trueni na fyddai mwy o staff yna i
siarad Cymraeg 'da fe," ("It's a shame there aren't
more staff to speak Welsh to him,") was this relative's
only comment, who then refused to discuss the matter
any further.

It seems that there are two reasons for this lack of
confidence:

(i) The traditional reluctance to complain of many
Welsh speakers, particularly to complain about
medical services.

(ii) The reluctance of the families of mental health
care users to draw attention to themselves and
to the fact that there is mental illness within

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their family. In interviews, more than one person
said that they had found this tendency not to
talk about mental health problems to be stronger
amongst Welsh speakers than amongst non-
Welsh speakers. More than one interviewee said
that they thought there was a greater stigma
attached to mental illness in Welsh speaking
society than in the wider community as a whole,
and that Welsh speaking families were more
likely to refuse to acknowledge that a family
member had such an illness. A member of a
schizophrenic family saw the need to hide
mental illness as a wider pattern of unease and
unwillingness to admit to problems within the
Welsh community. "As a community we are
under great pressure... and I think that we are
scared of anything that will rock our hold on
our future. Stigma is attached to mental illness
and probably more so within the Welsh speaking
community. We don't admit to alcohol or drug
problems. We don't admit to problems and
mental health is one of them."

The question which naturally follows on from this is
that of whether this unwillingness within the Welsh
speaking society to acknowledge a mental illness is
causing Welsh speakers to make less use of mental
health services than they could do. Another
possibility which has to be considered is that any
tendency to avoid formal mental health care service
in this way could be increased by a feeling that such
services do not provide for the particular needs of
Welsh speaking patients. It is interesting in this
matter to draw a comparison with the situation of
ethnic minorities in England, where the evidence from
hospital admission, local GPs' surgeries and
community surveys tends to suggest that people
living in England but born in Asia are less likely to
suffer psychiatric illnesses than people born in
England itself. This situation and its possible
implications were discussed in the NHS Ethnic Health
Unit's publication, Ethnicity and Health in England:

"It is not known whether these patterns reflect
genuinely lower levels of mental illness, or
differences in detection rates: they could reflect
the reluctance of Asians to report mental health
problems, or language and communication
difficulties making it harder for GPs to recognise
such problems when they arise. It is possible
therefore that there is an element of
unrecognised and untreated mental ill-health in
this ethnic group... It has been suggested that
there may be a considerable unmet need for
psychological support among black and minority
ethnic people, that many may not be getting the

type of service they require, and that some are
seeking it outside the NHS... Access to mental
health care may be limited by restricted
opportunities and insensitive services... The
difficulties of diagnosing illnesses like
schizophrenia in people of different cultural
backgrounds, and in those for whom English is
not the fi rst language, undoubtedly account for
some of the ethnic differences in levels of
diagnosed disease." (Balarajan & Raleigh, 1995)

According to Dr Dinesh Bhugra, Senior Lecturer at the
Institute of Psychiatry in London, the comparison in
Wales with ethnic minorities in England is very
appropriate. Speaking at the Conference of the
Psychotherapy Section of the British Psychological
Society in Gregynog in J une 1998, Dr Bhugra stated,
"In Wales the pattern for Welsh speakers seems to be
following that of ethnic minorities even in areas
where Welsh speakers form a native majority."

(Dube, S., 1998) During the same conference, Dr Dilys
Davies spoke of her experience of working in a region
where more than 60%[Caerfyrddin/Dinefwr] of the
population was Welsh speaking, but only around 10%
of patients receiving psychotherapy were Welsh
speakers. Dr Davies described this experience in the
context of the present crisis in agriculture:

"People like farmers are not coming into the
service and one possibility is that they don't
suffer emotional stress - that the Welsh speaking
population is an enlightened one. But a cursory
look at my own family show's that's not true. A
whole range of emotional disorders is apparent
in rural Wales as is shown by the high suicide
rate among Welsh farmers. There are huge
projects in England to deliver counselling for
different cultures like Asian and Afro-Caribbean
but a total absence of similar schemes in Welsh
speaking Wales, and people like farmers are
being missed out completely." (Dube, S„ 1998)

The impression Dr Davies also got during her work
was that the percentage of Welsh speakers was likely
to be higher on the general psychiatric wards, where
patients were more likely to receive physical and
chemical treatments, than the percentage amongst
outpatients, who received "talking treatments" more
often. This again coincides with the pattern found in
ethnic minorities in other countries. For example it is
noted in Ethnicity and Health in England:

"There is also compelling evidence of ethnic
differences in access to psychotherapy service.
African-Caribbeans are less likely to make
voluntary contact with health services
suggesting that such services may be

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

29

Chapter 7- Discussion Topics

unsatisfactory or inappropriate to their needs."
(Balarajan & Raleigh, 1995)

Dr Davies has offered her own analysis of the reasons
for the scarcity of Welsh speaking psychotherapy
patients in the part of Wales she was working in:

"A service set up by English speakers for English
speakers with complete disregard for the cultural
context."

At present, it is very difficult to conduct meaningful
research into patterns of access to psychotherapy in
Wales, since mental health statistics are not currently
collected for Wales as a distinct area - statistics for
England and Wales are collected in a manner which
allows analysis of the experience of the "Welsh" or
Welsh speakers as a distinct group. Equivalent
research in other countries has shown that different
ethnic groups do have different patterns of referral to
psychotherapy services, and that there is a tendency
on the whole for minorities and underprivileged
sections of society to receive less psychological help.

During the research for this report every NHS Trust in
Wales which provides mental health care and which
has prepared a statutory Welsh Language Scheme was
contacted by post to enquire about their arrangements
for dealing with Welsh speaking patients with mental
health problems. Of the eight Trusts who received
letters, four responded. Of these four:

• One said that it had no policy of noting
language choice, but that there was one Welsh
speaking Consultant available to patients who
wished to discuss their problems in Welsh.

• One acknowledged that it had a serious problem
of a lack of Welsh speaking staff, and said that
it was at the time setting about noting for which
jobs within the Trust the ability to speak Welsh
was either "essential" or "desirable".

• One said that she usually assesses a patient's
chosen language when they first meet - she had
also tried to solve the problem of lack of Welsh
speaking staff by adopting a team dimension.

"Because of a shortage of Welsh speaking staff in
some locations within our mental health services,
the staff who are available ensure that someone
who speaks Welsh is on duty at all times. Within
the community teams, work patterns are organised
to ensure that clients who wish to receive services
through the medium of Welsh can do that."

• One said that it was taking all possible steps to
ensure a Welsh-medium service to those who
desired one, including asking for assistance from
staff in other areas within the Trust region if

insufficient Welsh speaking staff were available
in any one area. It was also stated that the Trust
was currently introducing a system of stickers
on the covers of patients' notes indicating
language choice.

• According to a spokesperson for one Trust,
nursing staff were currently responsible for
noting language choice, but the Trust was also
in the process of reviewing its Welsh Language
Scheme in preparation for a merger with another
Trust as part of the government's reorganization
of the NHS in Wales. As part of this review, the
question of language choice had been noted as
one which needed to be discussed "to ensure
that language choice is continually recorded."

• Two of the Trusts noted that they had already
established, or were in the process of
establishing, Welsh language classes for staff,
with the intention of increasing the number of
Welsh speakers within the workforce.

Amongst the encouraging developments in the field
of mental health care in recent years, was the
establishment of the Gwynedd Welsh speaking Mental
Health Workers Group in 1995. The Group now co¬
operates with various public and voluntary bodies in
the fields of language and health to promote the use
of Welsh in mental health services. It also works to
promote the learning of Welsh amongst non-Welsh
speaking experienced mental health workers, and to
increase the recruitment of Welsh speakers into the
profession. During 1998, The Group began the task of
conducting a survey of how many bilingual mental
health workers are within the Gwynedd Community
Health Trust and what their jobs are. A spokesperson
for the Group expressed great satisfaction with
Gwynedd County Council's scheme to sponsor Welsh
speakers to qualify as social workers, suggesting that
a similar scheme to attract Welsh speaking nurses to
retrain as mental health nurses could be very
beneficial.

7.2.2 People With Learning Disabilities and Other
Special Needs

Whilst researching the needs of this category of
health care consumers, two types of people in
particular came to light, namely adults with severe
learning disabilities and children with special needs.

7.2.2.1 Adults With Severe Learning Disabilities

Of all Health Service consumers it is likely that those
with severe learning disabilities are amongst the most
vulnerable:

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WELSH IN THE HEALTH SERVICE:

Chapter 7- Discussion Topics

(i) Since they are often unable to express their
own wishes and depend on others to speak for
them.

(ii) Since they often have to depend on other
people to plan their lives and make key choices
on their behalf.

(iii) In the case of Welsh speakers with serious
learning disabilities, it can be difficult for
workers to identify the language choice of a
person who is largely unable to speak.

Regarding the third of the above 3 points, a certain
amount of evidence was found that less sensitive
staff are sometimes disregarding the possibility of
language choice for Welsh speakers with learning
disabilities by assuming that a person who cannot
speak does not have a preferred language. The
experience of bilingual workers in this field, and the
testimony collected in interviews with families, show
irrefutably the dangers of ignoring the language
choice of those without the power of speech. One
person described the experience of a member of her
family with a severe learning disability, who had
recently returned from a long period of residential
care when he had been cared for almost entirely
through the medium of English:

"Ddwy flynedd yn 61 nawr aeth e mas i'r
gymuned...'Oeddwn i'n pwyso pryd hynny i
wneud yn siwr fod e'n mynd yn 61 i awyrgylch
Cymraeg, achos mae'n dal i gofio'r geiriau
Cymraeg. 'Oedd y nyrs oedd gyda fe, Saesneg
oedden nhw, ond 'oedd 'na un oedd yn
digwydd bod yn yr ysbyty ac 'oedd hi'n dod a
siarad Cymraeg, ac 'oedd hi wastad yn dweud
bod e'n ymateb yn well."

("Two years ago he went out into the
community... I pressed at that time to make sure
he would go back to a Welsh speaking
atmosphere, because he still remembers things
like Welsh words. The nurses he had were English
speaking, but there was one who happened to be
in the hospital who would come to speak Welsh
to him, and she always said that he responded
better.")

In this case, a bilingual nurse was sufficiently
perceptive and sensitive to realise the linguistic
needs of a person with very limited powers of
speech.

Insufficient evidence was collected to enable drawing
any definite conclusions concerning this group of
particularity vulnerable consumers, and it is clear
that significant further research needs to be carried

out into their needs and the way they are met by the
Health Service and other public bodies.

1 . 2 . 2.2 Children With Special Needs

Firm evidence was found (see Section 7.3 below)
that a substantial number of medical practitioners in
several parts of Wales are continuing to tell some
parents not to speak Welsh to children with learning
disabilities for fear of further disadvantaging them.
Evidence was collected concerning two cases where
the happiness of families had suffered greatly after
health professionals advised parents not to speak
Welsh to their children, on the basis of the argument
that they had special needs which could be worsened
by having to cope with two languages. In one case,
the mother of one child switched overnight from
speaking Welsh with him to speaking only English to
him and to her other child. By now, these two
children are the only members of their large
extended family who cannot speak Welsh, and so
feel particularly isolated when the family gathers
together and they are unable to understand most of
the conversation going on around them. In the other
case, one couple's relationship broke down on
account of the tension which developed after a
health care practitioner advised them not to speak
Welsh to one of their children. One of the parents
was determined to continue speaking Welsh to the
child, while the other wanted to follow the
practitioner's advice. The child himself was in the
strange position of hearing one of his parents
speaking English to him whilst still speaking Welsh
to his siblings, leading once again to feelings of
isolation and separateness.

Although the difficulties which non-Welsh speaking
staff encounter when treating Welsh speaking
children have to be acknowledged, it is wholly
unacceptable for the providers of services to such
children and their families to insist that they should
alter the language of their home for their
convenience. This is a clear example of the
widespread tendency to place all responsibility for
ensuring a common language on the shoulders of
patients and their families, rather than on the
providers of care. The suggestion that speaking
Welsh to a child could intensify any special needs he
or she already has originates from a basic
misunderstanding of the nature of language and
bilingualism. It also does not take into consideration
the emotional and psychological implications for the
child as a family member if the language spoken
between him or her and his or her parents is English
whilst the rest of the family continues to speak
Welsh.

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31

Chapter 7- Discussion Topics

7.2.3 The Elderly

Although not every elderly consumer is necessarily a
vulnerable consumer, it is true that old age does
sometimes effect the ability of some people to express
their wishes and demand their rights as consumers.
These things can become even more difficult if the
elderly consumer is obliged to do it in his or her
second language. In the context of health care, old
age may also bring with it various sorts of illness and
frailty, meaning that older people are amongst the
most frequent users of the National Health Service.

During research work, three main categories of older
Welsh speaking consumers were identified who may
encounter problems if obliged to discuss health
matters or receive treatment through the medium of
English only:

(i) Those who have never fully mastered English,
generally because it has been a fairly
unnecessary language for them. These people
have lived most of their public and private lives
through the medium of Welsh in communities
where English was used only occasionally. They
may suffer genuine discomfort and confusion if
obliged by illness or frailty to move from their
Welsh speaking environment into health care
institutions where they may be expected to use
English as their main means of communication.
Whilst speaking during an interview about the
experiences of one elderly member of his family,
one man gave a neat, one-sentence verbal
picture of this sort of patient:

"Mae o'n 80 oed, ac mae ei Saesneg o yn eitha
bratiog, achos dyna ydy o."

("He's 80 years old, and his English is pretty
ropy, because that's just how he is." Lit.

"because that's what he is.")

Although such people only form a small part of Welsh
speaking society by now, their linguistic needs are
very genuine and serious consequences may follow if
they are disregarded.

(ii) Perhaps more common are elderly Welsh
speakers who are more or less fully bilingual,
but their second language is starting to
deteriorate as they age. This process is known as
"language attrition", and its effects have been
widely studied and recorded. For example, one
woman in her eighties described her own
experience of feeling her grip on English
gradually slackening, although she was a
professional who had worked most of her life in
English:

"Dw i ddim mor barod 'nhafod ag ydw i yn
Gymraeg, ac mae hwnna'n beth newydd i mi.
Wrth gwrs, dw i sbel dros 'mhedwar ugain, ac
dw i'n siwr fod o'n digwydd i bawb."

("I'm not so quick to respond as I am in Welsh,
and that's something new to me. Of course, I'm
a little over eighty by now, and I'm sure it
happens to everyone")

The same woman described how her late husband
would "ymbalfalu am y geiriau yn Saesneg" ("grope
for the words in English"), although he too was an
educated person, and had had wide experience of
public life in both English and Welsh. This testimony
was supported by the comments of a retired doctor
who spoke of his own extensive experience of
working in various hospitals:

"Be' dw i'di sylwi'n fwy na dim yw taw'r plant,
sy ddim wedi siarad lot o Saesneg, a'r henoed sy
'di anghofio lot o'i Saesneg yw'r mwyaf pwysig
i gael y Gymraeg drosodd iddynt nhw. Mae 'na
lot o bobl yn meddwl trwy gyfrwng y Gymraeg
- mae eu meddyliau nhw i gyd yn Gymraeg, fel
maen nhw'n cyfieithu yn eu pen os oes rhaid
iddyn nhw siarad yn Saesneg. A dw i'n meddwl,
fel bod pobl yn mynd yn hyn maen nhw colli'r
modd i wneud hynny yn hawdd."

("What I've noticed more than anything else is
that it's the children, who haven't spoken much
English, and the elderly, who've forgotten a lot
of the English, they are the most important
when it comes to using Welsh. A lot of people
think in Welsh - all their thoughts are in Welsh
so that they have to translate in their heads if
they have to speak English. And think, as people
get older they lose the ability to do that.")

(iii) Those who have suffered a stroke and in the
wake of that are able to communicate only in
their first language. Two people described in
very similar terms what happened when elderly
members of their families had strokes:

"Mi gath 'nhad stroc, a mi oedd o wedi colli ei
leferydd, ac 'oedd yn rhaid iddo fynd i'r ysbyty
am gyfnod o fisoedd. Mi oedd 'na nyrsys di-
Gymraeg yn gofalu amdano fo'r rhan fwyaf o'r
amser...'Oedd o yn ei saithdegau ac wedi treulio
ei oes yn siarad Cymraeg... Mi oedd o allan o'i
gynefin, mi oedd 'na afiechyd mawr wedi'i
oddiweddyd o."

("My father had a stroke, and he'd lost his
speech, and he had to go into hospital for
several months. There was a non-Welsh
speaking nurse looking after him for most of the

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time... He was in his seventies and had spent his
whole life speaking Welsh... He was out of his
natural environment, and this terrible illness had
overtaken him.")

"Mae hi'n 91, mae hi'n Gymraes iaith gyntaf, ac
mae'r Gymraeg yn haws iddi hi fel mae'n mynd
yn fwy methedig... Mae hi'n eithaf rhwystredig,
mae hi'n cymysgu, mae hi wedi cael sawl stroc.
Mae hi'n ffindo fe'n rhwystredig iawn. Wi'n ei
chlywed hi'n siarad Cymraeg a'r staff a dyn nhw
ddim yn deall gair o Gymraeg... Fe gath hi stroc
iawn yn ddiweddar, a buodd rhaid iddi fynd i'r
ysbyty... Ac 'oedd hi, yn wir yn anhapus iawn ar
adegau nag oedd 'na wasanaeth yn Gymraeg
iddi, ac 'oedd hi'n rhwystredig iawn. Oedd e
ddim gymorth o gwbl iddi w el I a. Ac 'oedd hi'n
dioddef o iselder, a lot o hynny oedd y ffaith
pan oedd hi'n byw yn ei fflat ei hunan, 'oedd
hi'n byw 90% neu ragor o'i bywyd hi yn
Gymraeg. 'Oedd bod yn fethedig, yn cael
trafferth gyda'i Ileferydd achos 'oedd hi wedi
cael y stroc mawr 'ma, a ddim yn gal Iu siarad
Cymraeg 'da pobl...wel, 'oedd yn ergyd greulon
iawn iddi."

("She's 91 and she's a first language Welsh
speaker, and she finds Welsh easier as she
becomes more frail. She's quite frustrated, she
gets confused, she's had several strokes. She
finds it very frustrating. I hear her speaking
Welsh to the staff and they don't understand a
word of Welsh. She had a very bad stroke
recently and she had to go into hospital. And
she was really very unhappy at times. It didn't
help her at all to get better. And she was
suffering from depression, and a lot of that
came from the fact that when she was living in
her own flat she used to live 90% or more of her
life in Welsh. Being disabled, having trouble
with her speech, and not being about to speak
Welsh with people - well, it was a cruel blow to
her.")

On the whole, the simple fact of the matter is that
elderly Welsh speakers are likely to feel a great deal
more comfortable and more at home whilst receiving
treatment if they are permitted to communicate, at
least some of the time, in the language through which
they live. Regarding this, the testimony of two
workers in two different hospitals is worth quoting
from. The first of these workers was a nurse, the
second a member of the kitchen staff:

"Yn enwedig 'da'r hen bobl... 'Oedd 'na ddwy ar
y ward lie 'on i, yn siarad Cymraeg, ac 'on
nhw'n falch bod rhywun yn gal Iu [siarad

Cymraeg], Daeth y person hyn Ian o casualty,
wi'n credu oedd hi jyst wedi [clywed] 'n acen fi
a wedodd hi'n syth "0, chi'n siarad Cymraeg," a
wedodd hi "0, diolch byth am 'ny.""

("Especially with the old people... There were
two women on the ward where I was, and they
were glad that someone could [speak Welsh],

This person came up from casualty, I think she'd
just [heard] my accent and she said straight
away, "Oh, you speak Welsh," and she said, "Oh,
thank goodness for that.")

"Mae 'na rai o'r hen bobl sy'n dod mewn, maen
nhw yn siarad Cymraeg. A mewn ffordd os ydyn
nhw'n gwybod bod rhywun yn siarad Cymraeg,
maen nhw ddiolchgar am 'ny. Chi'n gwybod,
ambell waith maen nhw'n siarad i nyrsys yn
Cymraeg a dyw'r rheini ddim yn gallu deall
nhw, a mae'r nyrsys yn dod ataf fi wedyn achos
maen nhw'n gwybod bo' fi'n gallu siarad
Cymraeg... A chi'n gwybod, ambell waith mae
hen bobl, maen nhw'n confused a ddim yn deall
bod nhw yn [yr] ysbyty, meddwl efallai bod nhw
gartref a maen nhw'n siarad i rywun sy' yn y
teulu mewn ffordd, maen nhw ddim yn deall
[taw] yn yr ysbyty maen nhw a siarad gyda
nyrsys... Pan maen nhw'n gweld fi, neu pan mae
rhywun yn dod i ymweld, maen nhw'n dweud,
"Mae hon yn siarad Cymraeg." Mae fel 'sen
nhw'n falch, a gwen ar eu hwyneb."

("Some of the old people who come in speak
Welsh. And in a way if they know that someone
speaks Welsh they're grateful for that. You know
sometimes they speak Welsh to the nurses and
the nurses don't understand them, and the
nurses come to me then because they know I
can speak Welsh. And you know sometimes old
people are confused and don't know they're in
hospital, they might be thinking they're at home
and speaking to a member of their family. They
don't understand that they're in hospital and
talking to nurses... When they see me, or when
someone comes to visit, they say, "This women
speaks Welsh." It's as if they're glad, and they
have a smile on their face.")

More than one person spoke of how they been
obliged to become ad hoc translators between an
elderly member of their family and hospital doctors,
and one nurse described how she would intercede
between elderly patients and non-Welsh speaking
doctors:

"Wi'n credu bod yr hen [bobl] yn falch iawn,
achos 'on i'n gallu gweud beth 'on nhw'n feddwl
yn well nag 'on nhw'n gallu gweud yn Saesneg.

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33

Chapter 7- Discussion Topics

'On i'n gal Iu gweud, "She is saying. This is what
she's saying to you.""

("I think the old [people] were very glad,
because I could say what they meant better than
they could say it in English. I could say, "She is
saying. This is what she is saying to you.")

One woman described clearly the serious
communication gap that she observed between non-
Welsh speaking doctors and a family member:

"Mae'r arbenigwyr geriatrics i gyd yn ddi-
Gymraeg. Aeth fy mam-yng-nghyfraith
oedrannus i mewn i ['r ysbyty lleol], "Daeth yr
arbenigwr efo'i haid o feddygon ifanc yn gofyn
cwestiynau iddi hi, ac roedd hi'n ateb pethau'n
anghywir. Wedyn dwedodd hi, "On i ddim deall
gair oedd o'n ddeud.""

("The geriatrics specialists are all non-Welsh
speaking. My elderly mother in law went into
[the local] hospital. The specialist came round
with his flock of young doctors, asking her
questions, and she was answering things
wrongly. Afterwards she said, "I didn't
understand a word he said."")

Another man spoke of the very positive experience he
had in one hospital, where staff went to considerable
trouble to ensure a certain amount of Welsh-medium
care was provided for a member of his family. This
man explained why he thought it was so important
that the hospital had gone to such trouble:

"Mae o'n 80 oed, ac mae ei Saesneg o yn eitha
bratiog, achos dyna ydy o. Pan oedd o'n wael
iawn efo niwmonia 'oedd o'n tueddu i fod yn
colli gafael ar eu synhwyrau a dim ond y
Gymraeg 'oedd o'n siarad. Os na fyddai rhywun
Cymraeg ar y ward ar yr adeg yna, fydden nhw
ddim yn gallu deall beth 'oedd o'n ddweud. Heb
y Gymraeg fydden nhw ddim yn gal lu
dehongli'r sefyllfa. Hynny yw byddai'r holl
geriach 'oedden nhw'n rhoi yn sownd ynddo fo
wrth gwrsyn rhoi darlun meddygol, ond beth
fydden nhw ddim yn neud oedd rhoi darlun o
sut 'oedd o'n teimlo a beth 'oedd o'n ceisio
ddweud wrthyn nhw."

("He's 80 years old and his English is pretty
ropy, because that's just how he is. When he was
very ill with pneumonia he tended to lose his
grip on his senses and he would only speak
Welsh. If there wasn't someone on the ward at
that time who could speak Welsh, they wouldn't
able to understand what he was saying. That is,
all the equipment they were hooking him up to
would of course give them a medical picture,
but what it wouldn't do is give a picture of how

he was feeling and what he was trying to tell
them.")

7.2.4 Young Children

(See also 7.3 Speech and Language Therapy and
7.4.1 Health Visitors)

Like the elderly, young children are some of the most
consistent users of the Health Service. Along with the
elderly, they are also one of the groups of consumers
who are most likely to be monolingual Welsh
speakers. Of course, when monolingual Welsh
speaking consumers come into contact with non-
Welsh speaking providers, there is a very basic
communication gap which cannot be easily bridged.
Attending hospital or a doctor's surgery can be a
frightening enough experience for many young
children, but it will be significantly worsened if the
child is obliged to go through the whole process in an
alien linguistic environment:

"It is confusing and frightening especially for
children who may speak only Welsh at home, to
be prodded around by someone with whom they
cannot communicate." (Eira Rowley of the Welsh
Society for Nurses, Midwifes ac Health visitors,
quoted in Walford, J., 1995)

As noted in the introduction to this report, during
research two basic categories of Welsh speaking
patients were identified. These two categories can be
used to divide up the testimony collected in
interviews concerning Welsh speaking children and
their experiences of health care:

(i) Those for whom Welsh language provision is a
clinical need during treatment, usually because
they cannot be effectively communicated with
except in Welsh. For example, one man spoke of
the communication difficulties which arose
when he took his ten year old daughter to
hospital after she had injured herself in an
accident:

"'Oedd pobl [yn yr ysbyty] yn garedig iawn, ond
'oedden nhw ddim yn sylweddoli. Roedden
nhw'n gofyn cwestiynau iddi hi oedd hi ddim yn
eu deall... 'Oedd y cwestiynau'n astrus ond
'oedden nhw hefyd yn Saesneg, ac ail iaith i [fy
merch] yw Saesneg. Ac wrth gwrs, 'oedd hi ei
gael yn anoddach i deall y cwestiynau 'na
byddai hi yn Gymraeg."

("The people in the hospital were very kind, but
they didn't realise. They were asking her
questions she didn't understand... The questions
were complex but they were also in English, and
English is a second language to [my daughter].
And of course she was finding it more difficult

34

WELSH IN THE HEALTHSERVICE:

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to understand the questions than she would in
Welsh.")

(ii) Those for whom it is a matter of good practice
to provide with services in their chosen
language where that is possible: One example of
this was related by a woman who described her
experience of taking a young girl to hospital
after an accident. This is an example of a
situation where Welsh was not essential for the
completion of the treatment, as the girl in
question was fully bilingual. Rather, it shows
how Welsh language provision can be good
practice, in that by using Welsh staff were able
to quieten a patient's fears and make her feel
more at home after a very distressing incident:

"Naeth un o'r plant syrthio a torri ei braich. Es i
a hi i children's casualty, ac 'oedd 'na nyrs 'fan
'ny oedd yn siarad Cymraeg. Cyn hynny 'oedd y
plentyn yn weddol hysterical... 1 oedd hi erioed
wedi bod yn yr ysbyty o'r blaen, ac 'oedd mewn
stad uffernol... Ond daeth y nyrs 'ma ac 'oedd
hi'n clywed ni'n siarad Cymraeg, a wedodd hi,
"0, ti'n siarad Cymraeg," a wedodd hi, "Ydw"
trwy'r dagrau i gyd... Dechreuon nhw gael sgwrs
ac ymhen dim 'oedd hi wedi cael jab a plastr ac
'oedd hi lot, lot, lot hapusach. Naeth e
wahaniaeth mawr.""

("One of the children fell and broke her arm. I
took her to children's casualty, and there was a
nurse there who spoke Welsh. Before that the
child was fairly hysterical... She'd never been in
hospital before, and she was in a terrible state...
But this nurse came along and she heard us
speaking Welsh, and she said, "Oh, you speak
Welsh," and she said, "Yes," through all the
tears... They started to chat and in no time at all
she had a jab and a plaster and she was a lot,
lot happier. It made a great difference.")

One thing which has been a cause of particular
anxiety to a number of the people interviewed is the
practice of allocating non-Welsh speaking nurses and
therapists to visit Welsh-medium schools. A letter was
received from one parent, describing his son's
experience with a non-Welsh speaking health visitor:

"Maefy mab yn uniaith Gymraeg ac yn
mynychu ysgol Categori A (cyfrwng Cymraeg).
Serch hynny, ymwelydd iechyd uniaith Saesneg
a ddaeth i'r ysgol i'w asesu. Dim ond trwy Iwc y
gallodd ei fam fod yn bresennol ac felly fe
fedrodd gyfieithu rhwng y ddau. Pwy a wyr pa
fath o asesiad a fyddai wedi ei dderbyn heb
hynny."

("My son is monolingual Welsh and attends a

Category A school (Welsh-medium). In spite of
that, it was a monolingual English health visitor
who came to the school to assess him. It was
only by luck that his mother could be there and
so she was able to translate between the two of
them. Who knows what sort of assessment he
would have received without that.")

Problems were also reported in one school when sight
tests were conducted. Children were asked to identify
the letter "u". During these, the children pronounced
the letter giving it it's Welsh sound (similar to a long
"ee"), causing the non-Welsh speaking nurse to
believe that they had mistaken the letter for an "e".
Evidence was collected also about the somewhat
clumsy attempts of some bilingual staff to translate
the words of various tests for children from the
original English into Welsh. In one case, a hearing
test depended on the ability to differentiate between
English words with similar sounds which were
presented in pairs. The words were translated into
Welsh on the spot whilst conducting the test, but
since the test depended on similarity of sounds in
English the effectivness was lost entirely when the
words were translated into very different sounding
Welsh ones - "dog" may sound like "hog" or "log" in
English, but "ci", "twrch" and "boncyff" are fairly
easily differentiated in Welsh.

Although it is generally children of primary school
age or younger who come to mind when discussing
those who have difficulties using English, one
secondary school teacher described the problems some
of her pupils encounter when communicating in
English:

"Mae ein hysgol ni yn ysgol Gymraeg, ac maen
nhw wedi penodi nyrs ardal sy ddim yn gal Iu
siarad Cymraeg. Ac mae lot fawr o'n disgyblion
ni yn lot mwy cartrefol yn Gymraeg... Er bod

nhw'n oedran ysgol uwchradd.Mae rhai

ohonyn nhw'n Gymreig iawn, dyn nhw ddim yn
gyffyrddus yn y Saesneg."

("Our school is a Welsh-medium school, and
they've appointed a district nurse who doesn't
speak Welsh. And an awful lot of our pupils feel
at lot more at home in Welsh... Although they
are of secondary school age... Some of them are
very Welsh, and they're not comfortable in
English.")

Although these points concerning health care workers
being allocated to schools are particularly relevant to
regions where Welsh is traditionally strong, and the
pupils therefore less likely to be used to speaking
English, one should not ignore the large number of
Welsh-medium schools in areas where Welsh, and

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

35

Chapter 7- Discussion Topics

Welsh language provision by the Health Service, are
traditionally weak, In several areas where the Welsh
language has not been traditionally strong for some
time, the new generation of children going through
Welsh-medium education means that the percentage
in the population of young people between 3 and
15 years old who speak Welsh is often a great deal
higher than the percentage of Welsh speakers in the
population in general. Looking at the counties of
Flintshire, Caerphilly, Blaenau Gwent and Torfaen as
examples, we see that the percentage of Welsh
speakers between 3 and 15 years old is more than
double the general percentage, and a similar trend is
to be seen in the populations of the counties of
Cardiff and Rhondda Cynon Taff:

All Welsh
speakers 3 years
and older (%)

Welsh speakers
3-15 years (%)

Blaenau Gwent

2.2

5.5

Cardiff

6.6

11.6

Caerphilly

6.0

14.6

Rhondda Cynon Taff 9.0

16.9

Flintshire

13.5

28.6

Torfaen

2.5

5.4

If these statistics come to be expressed in the future
in the form of an increasing demand for health care
services through the medium of Welsh, it is clear that
is will be necessary to significantly reassess
established ideas about how much Welsh language
provision is required for children in several regions.
This was acknowledged in the introduction to Gwent
Health Authority's Welsh Language Scheme where
only 2% of the population speak Welsh at the
moment:

"Rydym yn cydnabod fod diddordeb cynyddol
yn y Gymraeg yng Ngwent a bod ysgolion
Cymraeg yn ffynnu yn rhai o'r ardaloedd mwyaf
Seisnigedig. Feallai cenhedlaeth newydd o
siaradwyr Cymraeg fynnu eu hawl i ymwneud
a'r GIG lleol drwy gyfrwng y Gymraeg. Mae'n
bosibl y byddai llawer mwy yn gwneud hynny
petai ganddyn nhw hyder y gallai eu hymholiad
gael ei drin yn llwyddiannus drwy gyfrwng yr
iaith".

("We recognise that there is a growing interest
in Welsh in Gwent and that Welsh language
schools are flourishing in some of the most
anglicised areas. A new generation of Welsh
speakers might assert their right to relate to the
local NHS through the medium of Welsh. Many

more might already do so if they were confident
their query could be dealt with successfully in
the language.")

7.3 Speech and Language Therapy

There are two main reasons why this is one field
where it is particularly relevant to look at the issue of
Welsh language provision:

(i) It is area of work in which language and its use
are essential and integral elements.

(ii) Approximately two in every three speech
therapy patients are children, one of the four
key groups of vulnerable consumers named
above. In response to enquiries, two Community
Health Councils (Ceredigion and Pembrokeshire)
listed speech therapy as one of the particular
fields where the issue of Welsh language
provision has arisen, noting especially the needs
of young children in this regard.

The work of speech therapists is extremely varied, and
it often involves complex aspects of speech defects
and it is difficult to see how they can be effectively
treated in a bilingual patient without reference to
both the patient's languages. For example, in the case
of Receptive Phonological/Grammatical Disorders in
children, a patient has trouble understanding the
ambiguous ways language is sometimes used in
things such things a metaphors, sarcasm and jokes. In
a similar way, children with Semantic/Pragmatic
Difficulties are unable to master the rules and
conventions of conversation, and may introduce
irrelevant statements and fail to spot the signals given
by other people that they should speak or stop
speaking. These two disorders are obvious examples
of speech-related problems which involve to a large
extent an understanding of social and cultural
conventions which vary between linguistic
communities.

In 1990, the need for bilingual therapy for bilingual
patients was recognised in the Royal College of
Speech and Language Therapists' Professional Code of
Conduct:

"One of the most optimistic findings which
comes from the latter day literature is that
bilingualism in a child or adult is an advantage
and rarely a cause or exacerbating feature of
any disability. Thus, the good speech therapist
must use both (all) the languages which clients
use or are exposed to in their daily lives to
differentially diagnose the language impairment
and to counsel and remediate. A decision not to
use the facility of the client's two (or more)
languages and possibly work in the client's less

36

WELSH IN THE HEALTH SERVICE:

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developed language because it is the one shared
by the therapist, cannot be clinically upheld."
(Royal College of Speech and Language
Therapists, 1990)

This was reinforced on a practical level by one parent
who spoke about his child's dyspraxia:

"Mae'n ychydig bach o joc bod chi'n asesu
plentyn Cymraeg yn Saesneg ar gyfer therapi
iaith.... Mi fyddai'r synau'n cael eu plethu, peth
fel "bydd" a "byth"... ac ych chi angen cymorth
penodol... Yn amlwg, mae plentyn Cymraeg dan
anfantais."

("It's a little bit of a joke trying to assess a
Welsh speaking child in English for language
therapy... The sounds used to get mixed up,
things like "bydd" and "byth"... and you need
particular help... Obviously, a Welsh speaking
child is at a disadvantage.")

In this case, it is clear that the child needed treatment
from a therapist who could at least recognize and
differentiate between the sounds of the Welsh
language.

On a more serious level, there is a certain amount of
evidence that some speech-impaired patients have
been treated unsuccessfully, or even received the
wrong treatment, because there were no Welsh
speaking staff available to work with them. In one
case, a patient was obliged to take part in a course of
treatment which worsened his condition because non-
Welsh speaking staff believe that the mixture of
swear-words and Welsh he was speaking was simply
meaningless jargon. The patient was in fact
attempting to explain in Welsh that the treatment was
unsuitable. In another case, a patient's course of
treatment in an English hospital was ended when staff
decided his speech could not be restored, but when
the same patient was moved to a hospital where he
could be treated through Welsh it was found that his
speech defect was one which could be successfully
treated.

On a different level, testimony was recorded about the
personal and emotional effect of providing
monolingual English speech therapy for patients who
have grown used to communicating mainly through
Welsh. In the particular case looked at, it was reported
how an elderly women received intensive speech
therapy after an accident which affected her speech.

No enquiries were made as to what was her first or
preferred language before beginning the therapy,
which was performed in English with some success.
When the women saw her son for the first time after
this course of treatment she greeted him in English -
the fi rst time ever she had spoken that language to him.

The 1991 Welsh Consumer Council report, Speech
Therapy and Children in Schools, showed that there
was a serious lack of speech therapists in Wales, and
that as part of this there was shortage of therapists
able to practice in Welsh. According to the most
recent Welsh Office statistics, on 31 March 1998 there
were 275 speech therapists employed by the National
Health Service in Wales (229 whole time equivalent),
as well as 36 auxiliary workers of various sorts (27
wte). This is a substantial improvement since 1988,
when there were 144 therapists working in Wales
(wte). In 1989 Enderby and Davies looked at the
workloads of speech therapists and at therapy needs
within the population, and came to the conclusion
that 26 speech therapists are needed for every 100,000
people. This gives a required total of 754 therapists
for the Welsh population of 2.9 million people - more
than 3 times the present total (wte). Statistics
recording how many of these are able to practice in
Welsh are not kept centrally, and it would be
necessary to conduct a comprehensive survey of all of
the 20 NHS Trusts in Wales which employ speech
therapists to see to what extent Welsh language
provision is available in this field. However, even
though the relevant statistics have not yet been
centrally collected, the shortage of suitable speech
therapists for Welsh speaking school children is an
obvious problem which a number of public bodies are
very aware of. According to a spokesperson for the
Welsh Language Board, approximately two out of
three counties in Wales do not have even one speech
therapist who is sufficiently fluent to practice through
the medium of the language: and comments and
complaints about this shortage feature strongly in the
correspondence received by the Board's Education
Department. On the whole, the Welsh language
provision in this field is very inconsistent, depending
to a large extent on where the patient happens to live

In the face of this shortage, two things are clear:

(i) J ust as in all other medical fields, there is a need
to attract more bilingual students to qualify as
speech therapists. To this end, significant work
has been carried out in Gwynedd, going into
Welsh-medium schools to advertise speech
therapy to students as a possible career choice.
Open days have also been held in training
centres for students from schools and tertiary
colleges, with a presentation by a newly-
graduated therapist about the nature of the
training and the job itself. Health care bodies in
Gwynedd, with the assistance of the Welsh
Office, have also sponsored a number of local
students to study speech therapy. As a result of
this, Gwynedd now produces more speech

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

37

Chapter 7- Discussion Topics

therapists than can be employed in the region. On an
all-Wales level, a Welsh Language Steering Group has
been established to look at training in Welsh language
speech therapy for those who are currently studying
to become speech therapists (pre-qualificational
training). A Specific Interest Group has also been
created to look at Welsh language training for those
who are already working as speech therapists (post-
qualificational training). The Steering Group is also
looking into the possibility of establishing a resource
centre for Welsh speaking therapists. In addition to
this, a draft questionnaire is being prepared asking
Welsh speaking therapists about such things as how
many Welsh speaking clients come to them for
treatment, how much training they have received to
deal with these clients, and how much they would
like to receive.

(ii) J ust as in every other medical field, there is a
need for effective arrangements to ensure the
services providers are aware which patients need
Welsh-medium speech therapy, and to ensure
that bilingual therapists are placed with patients
wherever possible. Regarding this, it is worth
referring to the Welsh speaking therapist sharing
arrangement which has been established
between the counties of the former county of
Gwent - Caerphilly, Blaenau Gwent, Torfaen,
Monmouthshire, and Newport - where there is a
serious shortage of therapists able to practice in
Welsh. This sort of co-operation between
counties is essential if we are to address the
increasing need for Welsh language provision
where it has not traditionally been available,
and is to be strongly recommended to other
regions where there is a shortage of Welsh
speaking therapists.

There is no denying that bilingual therapists are a
valuable asset to their employers, and it can be
argued that as many as possible of them should be
recruited, whatever the percentage of Welsh speakers
is in the region served. The reasons for this are simple
enough

(i) As the figures for various counties quoted in
Section - 7.2.4 Young Children show, local
patterns of Welsh speaking are changing
dramatically, with a significant increase in
Welsh speakers aged 3 to 15 which may have
long-term effects on patterns throughout the
entire population over time. As in all other
fields, the provision of Welsh-medium services
cannot, therefore, be sensibly based on present
demand.

(ii) If a bilingual therapist conducts a clinic, there is
no need to organize particular staff to treat
Welsh-and English speaking patients separately,
as a bilingual practitioner can deal with both
groups of patients with equal ease. A bilingual
therapist can also switch between the two
languages as required when dealing with
individual patients, rather than having to call on
additional help to treat one of them or being
obliged to ignore one of them. In this
bilingualism is the skill which makes the
bilingual therapist so valuable, rather than the
ability to use any one language. For example,
evidence was collected concerning one stroke
patient who was mixing Welsh and English
words together, producing such oddities as
"dinio" (combination of the English word
"dinner" and its Welsh equivalent "cinio"). This
was a problem the bilingual therapist was able
to recognize immediately in a way that a
monoglot person would not be able to do. It was
also reported by one bilingual therapist that
some bilingual stroke patients may speak one
language and write in the other; a situation
which again requires the assistance of a
bilingual practitioner.

As in the case of health visitors (see 7.4.1 below), it
is clear from the evidence collected that the attitudes
of speech therapists to the Welsh language are often
viewed as being as important as their abilities in the
language in the minds of their Welsh speaking clients.
Whilst many Welsh speaking consumers, particularly
in the south-east, are willing to accept that a
comprehensive Welsh language service cannot be
easily provided every time, many people have been
angered by the negative attitudes of medical staff to
the language. One can refer for example to the recent
testimony of Caryl Parry J ones as reported in the
Welsh language weekly Y Cymro, concerning her
experience of taking her child before a speech
assessment panel:

"Roedden nhw'n bobl alluog, sensitif, ond heb
ddeall dim am y Gymraeg. Y cwbl oedden nhw
am wybod oedd faint o Saesneg oedd ganddo -
cons'rn mawr am hynny - ac awgrymu ein bod
ni'n ei symud o'i ysgol Gymraeg i ysgol gynradd
Saesneg ."

("They were capable, sensitive people, but they
didn't understand anything about Welsh. All
they wanted to know was how much English he
knew - they were very bothered about that -
and suggested that we move him from his Welsh
school to an English-medium primary school.")

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Although some difficulties are bound to arise when a
monolingual Welsh speaking child comes into contact
with a service which is provided through English, it is
wholly unacceptable for service providers to claim
that it is the child's language which is the problem
rather than any inadequacies of the service. This is a
clear example of a service provider insisting that
consumers should adapt to suit the service, instead of
the service being adapted to respond appropriately to
the needs of consumers. It also shows an old-
fashioned and Anglocentric attitude towards
bilingualism and minority languages - the sort of
attitude for which there should be no place in a
modern Health Service. Bilingualism is generally
recognised by now as being advantageous to children,
there is therefore no reason why it should be seen as
a disadvantage to a child with a speech defect.

7.4 Care in the Home

Although many Welsh speakers accept to a large
extent that they will have to use English when
visiting the doctor's surgery or the hospital, a far
more uncomfortable experience for many is having to
change the language of their household in order to
accommodate a non-Welsh speaking health worker
who is providing a service in the home. This difficult
situation can be even further worsened if that worker
displays negative attitudes towards the usual
language of the household.

7.4.1 Health Visitors

In all the discussion conducted with consumers, one
issue which was raised with remarkable regularity was
the question of non-Welsh speaking health visitors
treating and assessing monolingual Welsh speaking
children. Almost all interviewees who had young
children spoke of having problems of one sort or
another with health visiting services, and many other
people described unpleasant experiences which friends
or members of their families had had.

The Beaufort Research survey conducted for this
report showed that only 27% of the respondents who
had seen a health visitor would usually use Welsh
with him or her. This means that 73% of Welsh
speakers either chose to or are obliged to use English
when receiving health visitor services in their homes.

It is hardly surprising therefore, that health visitors
were noted in the 1997 Community Research Project
carried out by Cardiff University on behalf of the
Welsh Language Board, as one of the groups of key
individuals who may have a negative impact on
patterns of use of Welsh in the community. (Williams,
C. & Evas, J., 1997)

The evidence collected shows that Welsh speaking
consumers face two main problems when dealing with
non-Welsh speaking health visitors:

(i) The practical problem that a monoglot Welsh
child and a monoglot English health visitor have
no common language between them. Effective
two-way communication is therefore not
possible. This creates particular problems when
the health visitor is trying to conduct language
and understanding tests on the child.

(ii) A problem of a different nature is that which
has arisen with some non-Welsh speaking health
visitors: their negative and insulting attitudes
and comments when dealing with Welsh
speaking families. As noted below, some have
gone as far as trying to influence parents to
raise their children as monoglot English
speakers.

Attention was drawn to the first of these two
problems in 1995 by Eira Rowley of the Welsh
Society for Nurses, Midwifes and Health visitors:

"If Welsh is the child's first language and the
health visitor does not speak it, any
development test you do will be null and void
because they just do not respond the same when
their mother is having to translate... It has led to
children being labelled slow."

(Walford, J., 1995)

And in response to an enquiry in September 1998, the
Chief Officer of one Community Health Council
confirmed that it continued to be a cause for concern
in her area:

"There are often particular areas of concern e.g.
speech therapists, health visitors etc., whose
day-to-day contact with children (first and often
the only language at a young age is Welsh) and
the elderly (some of whom revert to first
language after strokes etc.) can be hampered to
a language barrier to communication."

Evidence was collected in interviews with parents on
two situations which show the kind of difficulties that
can arise when health visitor services are not planned
bearing the needs of monolingual Welsh speaking
children in mind. The two situations are described
below in brief:

(i) A health visitor went to a family in order to
conduct an intelligence test on a young child
based on recognition of illustrations of different
objects on cards. The test was conducted in
Welsh but difficulties arose because the test had
been planned in English on the basis of a
vocabulary that an English speaking child would

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

39

Chapter 7- Discussion Topics

be likely to know by a specific age. For
example, a picture of a duck was presented -
although the word "duck" is comparatively easy
to say, a Welsh speaking child is not as likely to
be able to say "hwyaden" or Chwaden."

(ii) A non-Welsh speaking health visitor had learnt
the necessary Welsh vocabulary to conduct the
same kind of intelligence test described above
but problems arose when the child started giving
answers which whilst correct, did not conform
to the "standard" answers that the health visitor
had. The mother of the child had to interject
after the child had been marked incorrect for
naming a picture of a boat as "bad."

In all the interviews with consumers, health visitors
were the only section of non-Welsh speaking medical
practitioners that people said they were ready to
refuse their service. That was done in all cases as
consumers did not believe that non-Welsh health
visitors could make a correct and safe assessment of
the health and intellectual ability of their Welsh-only
children. One person explained that it was easier to
demand a Welsh speaking service for his child than
for himself:

"We asked for someone Welsh speaking in the
case of a health visitor and not in the case of
the midwife... It makes it easier to ask because
we are not doing so for 'selfish' reasons."

On the whole it was educated and confident
consumers from a middle class background that
tended to do this, and that is not surprising when
considering the nature of the system which allocates
health visitors to families. Because families are not
asked whether they would prefer to have a bilingual
health visitor, if a family is to receive a service in
Welsh they often have to refuse personally any
monolingual English health visitor when they arrive
at their home. This, of course, is a very unpleasant
experience for the health visitor and also for the
family, because it turns a matter which should be
purely administrative to a personal confrontation on
the doorstep. In the worst example encountered, one
woman said that she had had to argue for 20 minutes
with a non-Welsh speaking health visitor sent to her
home before receiving a promise that a bilingual
health visitor would be sent the next time.

In order to avoid such personal confrontation, there
are strong arguments for asking families what
language they speak at home before allocating a
health visitor to them. To do that, the Health Trusts
would have to recognise the Welsh language as a
valuable professional skill amongst their staff, and as
a valid consideration when allocating staff to clients.

Considerable waste of linguistic skills are seen at
present because language is not considered when
allocating health visitors to specific families. Present
services tend to go against language choice. The
reason for this is that individual health visitors are
linked to surgeries, and service specific regions. This
means that a team dimension is more difficult, and if
there isn't a Welsh speaking health visitor within the
practice, it isn't easy to provide a Welsh service to the
residents.

While a number of Welsh speaking families will
receive a second-rate service for their children
because of communication difficulties between the
child and the health visitor, it is likely that some
health visitors do not use their bilingual skills to the
optimum because they have been placed with
monolingual English families that do not need Welsh
language provision. Bearing this in mind, giving
consideration to language when planning health
visitor services could be of benefit to clients and staff
alike; the clients would have a better chance of
receiving the Welsh language service they desire and
staff would have a better opportunity to practice their
bilingual skills and therefore develop professionally.

Worst of all, there is evidence that some health
visitors put pressure on parents to change the
language they use with their children from Welsh to
English. Cases of this were encountered in traditional
'non-Welsh speaking' regions and also within regions
where Welsh speakers form the majority of the
population. One young mother described her
incredulity when one health visitor challenged her for
speaking Welsh to her child:

"Daeth hi i'r ty, ac 'oedd hi'n siarad gyda fi am
sbel fach, rhyw bum munud. Wedyn clywodd hi
fi'n siarad Cymraeg gyda'r babi, wedodd hi, "Oh,
what language is that you're speaking?" Wedais
i taw Cymraeg oedd hi, wedodd hi, "Is that
right? It's not relevant," a beth arall wedodd hi?,
"Not relevant" a "Won't it harm his ability to
pick up English?" Nes i ddim dweud unrhyw
beth ar y pryd, oherwydd o'n i mewn cymaint o
sioc."

"She came to the house and spoke to me for
about five minutes. She then heard me speak
Welsh to the baby and said: 'Oh what language
is that you're speaking?' I said that it was Welsh
and she said 'Is that right? It's not relevant' and
what else did she say, 'Not relevant' and 'Won't
it harm his ability to pick up English.' I didn't
say anything at the time because I was in a state
of shock."

Gwenan Thomas recorded a similar example during
her research into the experiences of pregnant women

40

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in the catchment area of Glangwili hospital. A mother
talked about her experience when a health visitor
came to the house to see her two year old child:

'I don't think Ifan understands a lot of English,
he didn't when the health visitor came. So she
said that we should be speaking English to him,
or that we would have big difficulties later on
and that he wouldn't develop properly.'

(Thomas,G, 1998).

Of course, such old-fashioned and mistaken attitudes
to bilingualism and minority languages is totally
unacceptable, especially among health care
professionals. Perhaps some parents will be confident
enough to disregard such baseless advice, but for the
less confident and less experienced, it is likely to lead
to confusion and uncertainty during a difficult and
very important period in their lives.

7.4.2 Ongoing Care in the Home

When researching the subject of care in the home,
another point raised by some Welsh speaking
consumers is what happens when a member of their
family is suffering from a long-term illness and has
to receive ongoing care at home. Although it was not
possible to research very widely in this field, what
little testimony was collected from consumers tends to
reinforce what was said by others about health
visitors (see 7.4.1 above), specifically that there is a
lack of consideration for language needs, and the
non-Welsh speaking are being allocated to Welsh
speaking families with no enquiries being made as to
whether the family would prefer a Welsh speaker. As
in the case of health visitors, families then have two
equally unsatisfactory options: either to accept the
non-Welsh speaking worker and forfeit their right to
language choice; or to face a personal confrontation
with the individual worker when he or she comes to
the house, and turn him or her away on the doorstep.

In an interview, one woman described her own
experience of trying to secure Welsh-medium cancer
care at home for her father:

"Fi ddaru ei gyfeirio fo [at y gwasanaeth gofal
cartref], a nes i ddeud bo fi'n teimlo bod hi'n
bwysig iawn fod o yn cael nyrs Gymraeg. A
rhywun Saesneg sy wedi dod i'r ty... 0 be' dw
i'n wybod amdan 'yn rhieni, dw i'n gwybod y
basen nhw wedi bod yn hapusach efo rhywun
Cymraeg. Mae'n anodd iawn, dw i'n meddwl,
pan wyt ti mewn sefyllfa o fod yn glaf, 'wyt ti i
ddechrau efo'r imbalance of power... Mae 'na
ddigon i boeni amdano heb orfod creu
annifyrrwch. Dan ni'n teimlo weithiau bo' chdi'n
mynd i greu annifyrrwch, neu bo' chdi'n cael dy

labelu fel person anodd.... Os dw i'n mynd i'r ty,
a'r nyrs yno, wel mae'r tri ohonon ni'n gorfod
siarad Saesneg. Mae o'n creu rhyw sefyllfa sy
ddim yn normal... Dw i ddim yn gyfforddus -
mae 'na ryw deimlad bod ni i gyd yn ffalsio.
Dydy o ddim yn naturiol."

("It was me who referred him [to the service],
and I said that I felt it was very important that
he had a Welsh speaking nurse. But it was an
English speaker who came to the house... From
what I know about my parents, I know they
would have be happier with a Welsh speaker. It's
very difficult, I think, when you're in the
situation of being a patient, you start with an
imbalance of power... There's enough to worry
about without creating unpleasantness. We feel
sometimes that you're going to create
unpleasantness, or that you'll get labelled as a
difficult person... If I go to the house and the
nurse is there, well the three of us have to speak
English. It creates some sort of abnormal
situation... I'm not comfortable - there's some
sort of feeling that we're all being deceitful. It's
not natural.")

The same woman went on to describe how the family
felt that it was their responsibilty to make the service
provider feel comfortable, rather than the provider
making them as consumers feel at ease whilst
receiving the service:

"Pan wyt ti'n derbyn gwasanaeth, y peth sy'n
bwysig ydy bo' chdi'n teimlo'n esmwyth, bo'
chdi'n teimlo'n hapus efo pwy sydd yn dod i dy
weld ti, a bod nhw yna i dy gefnogi di, yn
hytrach bo' chdi yna i neud iddyn nhw deimlo'n
gyfforddus. A weithiau dw i'n meddwl mai
dyna'r sefyllfa: pan maen nhw'n dod i dy gartref
di bo' chdi'n gorfod neud ymdrech i neud iddyn
nhw deimlo'n gyfforddus, oherwydd bo' chdi'n
ymwybodol bod nhw'n gwybod bod chi i gyd
wedi gorfod newid eich iaith oherwydd bod nhw
yna."

("When you're receiving a service, the important
thing is that you feel at ease, that you feel
happy with who's coming to see you, and that
they are there to support you, rather than you
being there to make them feel comfortable. And
sometimes I think that's what happens: when
they come to your home, you have to make an
effort to make them feel comfortable, because
you're aware that they know that you've had to
change your language because they're there.")

A similar experience has been described recently by
Rhian Fluws Williams, Head of CCETSW Cymru, who
also offered her own analysis of what happened:

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41

Chapter 7- Discussion Topics

"I recently lost my mother. During the last
weeks we were given the support of a truly
delightful Macmillan nurse. She had excellent
skills for providing support for both my mother
and ourselves as a family. Unfortunately,
however, she did not speak Welsh, and so during
this traumatic period the language used in the
bedroom where we as a family gathered around
our mother, often had to switch to English. This
did not cause much trouble and, yes it did
succeed. However that is not the point. Speaking
English meant we weren't completely ourselves.
Therefore I would argue that, despite the
excellent service we received, it was not fit for a
purpose as far as our family was concerned and
especially my mother. The nurse did not have all
the necessary skills required in this situation."
(Roberts, G„ 1997)

The little evidence collected about ongoing care in the
home supports what consumers said about health
visitors (see 7.4.1 above) and the evidence from
pregnancy and midwifery (see 7.5 below). These three
areas show clearly that more attention and better
preparation is needed to meet people's needs where
possible.

7.5 Pregnancy and Midwifery

This is a field where the contact between the
consumer and the Health Service is one which
continues for several months during one of the most
important periods in the client's life. In 1993, in the
report Changing Childbirth, the Health Department's
Expert Maternity Group acknowledged the importance
of the period of pregnancy and birth in the lives of
women, and set out an agenda for ensuring that
pregnancy and birth were not only safe experiences,
but also positive and life-enriching ones. According
to Changing Childbirth, care should be planned
around the mother, responding to her particular
needs. This "woman-centred care" is described in the
report's opening sentence:

"1.1 Every woman has unique needs. In addition
to those arising from her medical history these
will derive from her particular ethnic, cultural,
social and family background. The services
provided should recognise the special
characteristics of the population they are
designed to serve."

According to a recent study by a midwife working in
west Wales, this is not happening:

"In an era of woman-centred care, choice and
empowerment, many women in Wales are being
oppressed and disempowered. The lack of

language sensitivity, oppression and
disempowerment affects the quality of care and
may have repercussions on the outcome of
pregnancy." (Thomas, G„ 1998)

Gwenan Thomas, a midwife from Lampeter, studied
23 Welsh speaking women from Carmarthenshire and
south Ceredigion, chosen at random by Thomas'
colleagues from amongst the Welsh speakers in the
Glangwili Hospital catchment areas who had given
birth in the previous 6 months. Of these 23, all but 2
spoke Welsh as their first language. Thomas did not
find any kind of feeling amongst the women that
they were using the Welsh language in order to make
a stand on principle or for any nationalistic reasons;
rather, she came across varying patterns of using the
language to differing degrees in the home, the
workplace and when socialising as a natural
communication medium. There was a large group who
were able to speak English well but said that they
preferred to use Welsh; the others all considered
themselves to be fully bilingual and had no language
preference. Although not every one of them spoke
Welsh with her husband or partner, all of the women
used Welsh with their child/children.

The 23 women had very varied experiences of Welsh
language provision or the lack of it. Some of the
women who did get a certain amount of service in
Welsh described the variety of positive feelings they
felt when receiving that service:

(i) Relief: "Fel mae'n digwydd wedyn, Cymraes
naeth ein derbyn ni fewn i'r ward. O'n i'n poeni
am fynd mewn, ond pa siaradodd hi Gymraeg a
ni roedd rhyw rhyddhad."

("As it happened, it was a Welsh speaker who
welcomed us into the ward. I was worrying
about going in, but when she spoke I felt some
sort of relief.")

(ii) Feeling more at home : "Mae siarad Cymraeg yn
gret, hela ti i deimlo'n gartrefol."

("Speaking Welsh is great, it makes you feel at
home.")

(iii) Greater confidence in the midwife : "Unwaith
oedd y ferch [y fydwraig] Gymraeg wedi rhoi
ateb i fi roeddwn i'n gwybod fod popeth yn
iawn. Roeddwn i'n hapusach, roedd real ffydd
'da fi ynddi. A lie hi ddim dweud celwydd wrtho
fi yn Gymraeg."

("As soon as the Welsh speaking [midwife] had
answered me. I knew everything was alright. I
was happier, I really trusted her. She couldn't lie
to me in Welsh.")

"Fi'n siwr oedd y ffaith bod [y fydwraig] wedi

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WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

siarad Cymraeg wedi 'neud gwahaniaeth. Wei,
'oedd 'da fi ffydd ynddi straight away."

("I'm sure that the fact that [the midwife] had
spoken Welsh made a difference. I trusted her
straight away.")

(iv) Greater confidence in themselves : "Fi'n gryfach
yn Gymraeg, mwy eofn ac yn well yn
Gymraeg."

("I'm stronger in Welsh, more fearless and better
in Welsh.")

"Fi'n nerfus un Saesneg, ond yn Gymraeg fi
mwy relaxed a mwy confident."

("I'm nervous in English, but in Welsh I'm more
relaxed, more confident.")

The opinion of some staff that they could get better
information from patients by speaking Welsh to them
was noted above in Chapter 5 ■ The Language of
Medicine. That testimony is backed up in a very
negative way by the confessions of some women
questioned by Gwenan Thomas who said that they
had failed to ask about some things they wanted to
know, because there was no opportunity for them to
do so in their chosen language. The testimony of
these women shows that important information is not
being transferred between staff and patients because
of a fundamental communication gap. According to
Thomas' study, it is the pregnant women rather than
the staff who are deemed to be responsible for
bridging that gap, something they do not always feel
able to do:

"Fi'n teimlo fy mod i'n gal Iu cael fy mhwynt
drosto yn haws yn Gymraeg na pan wi'n siarad
Saesneg, falle swn i ddim yn cael pethau drosto
mor glir yn Saesneg. A hefyd ma'r teimlad
weithio o deimlo yn dwp o siarad Saesneg. Falle
wedyn ma fe'n rhywddach peidio gweud dim."

("I feel I can get my point across easier in Welsh
than when I'm speaking English. Perhaps I
wouldn't put things so clearly in English. Also, I
sometimes feel stupid when I'm speaking
English. Perhaps then it's easier just to say
nothing")

"Ti'n gwybod beth ti'n meddwl yn Gymraeg, a
falle bod ti ddim yn gal Iu cymharu fe yn
Saesneg. Ti'n gorfod meddwl dwy waith beth
ti'n mynd i weud yn Saesneg. Wedyn ma fe [am]
bell waith yn rhwyddach i beidio gofyn y
cwestiwn o gwbl."

("You know what you mean in Welsh, and you
might not be able to do the same thing in
English. You have to think twice what you're
going to say in English. So it's easier sometimes
not to ask the question at all.")

These experiences all run completely contrary to the
principles set out in Changing Childbirth, as can be
seen from Chapter 2 of that document, Appropriate
Care:

"The Expert Maternity Group believes that the
first principle of the maternity services should
be:

The woman must be the focus of maternity care.
She should be able to feel that she is in control
of what is happening to her and able to make
decisions about her care based on her needs,
having discussed matters fully with the
professionals involved." Also relevant in
connection with this is Sub-heading 3.6 Making
the Best Use of Services:

"3.6.2 Providers must ensure that the woman is
seen as the focus of care and that her views and
needs are respected. When women have more
complex needs, or they find it difficult to
articulate them, care must be taken to create a
genuine opportunity for the woman to explain
her views and concerns."

The communication gap between Welsh speaking
mothers and non-Welsh speaking staff is seen at its
most extreme during the period of the actual birth. In
an interview, one mother of a young child spoke of
how she had completely lost the ability to speak
English when giving birth. And this in spite of the
fact that she was an educated woman who could
normally speak English to a high standard:

"Nes i ddim siarad Saesneg o gwbl trwy'r
genedigaeth. 0 feddwl yn 61, tasai [fy ngwr]
ddim wedi bod yna baswn i wedi cael lot mwy o
drafferth, a basai hynny wedi bod yn anodd. Dw
i ddim yn meddwl baswn i wedi gal Iu siarad
Saesneg i safio 'mywyd 'on i mor focussed ar
jyst y genedigaeth, fel 'doedd 'na dim byd arall.
Ac yn ami 'oedden nhw jyst isho ateb "ie" neu
"na". Bydden nhw'n gofyn i mi, "Do want a
drink of water," ac 'o'n i'n deud [wrth fy ngwr],
"Na, deud wrthi hi bo' fi'n iawn." Basai wedi
bod yn haws, si wr o fod i ddeud "No" yn
Saesneg, ond y ffaith oedd bo' fi'n deud "Na,
deud wrth i hi bo' fi' iawn" neu bo fi ddim isho
fo neu beth bynnag. 'Oedd o'n fwy o eiriau [yn
Gymraeg], ond 'oedd o'n haws."

("I didn't speak English at all during the birth.
Thinking back, if [my husband] hadn't been
there I would have had a lot more trouble, and
that would have been difficult. I don't think I
could have spoken English to save my life - I
was so focused on the birth, there was nothing
else. And often they just wanted a "yes" or "no"

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

43

Chapter 7- Discussion Topics

answer". They would ask me, "Do you want a
drink of water," and I would say [to my
husband] in Welsh, "No, tell her I'm alright." It
would have been easier just to say in English
"no", but the fact was that I was saying it in
Welsh, "No, tell her I'm alright," or that I didn't
want it or whatever. It was more words [in
Welsh] but it was easier.")

In Gwenan Thomas' study, another mother described
her experience of having to use her husband as an
interpreter between herself and her non-Welsh
speaking midwife during the second period of labour,
even though the two women had been happily
speaking English to each other only a short while
before. This mother spoke of the guilt she felt that she
could not respond to the needs of her midwife by
speaking English to her. One theme which Thomas
clearly identified during her research was that it was
the pregnant women who generally shouldered the
responsibility for speaking a language which those
around them were comfortable with, a firm indication
that the service was being provided in a way which
was convenient for the provider rather than being
suitable for the consumer.

As found during the research into midwifery and
health visitor services for this report, Thomas noticed
that no consideration was given to women's language
choice when allocating midwives to them, although a
number of them would have preferred a Welsh
speaking midwife:

"Sadly, despite identifying the attributes of
being able to speak their chosen language, none
of the women considered they had a choice in
the matter. They were never offered the option
of having a Welsh speaking midwife.
Furthermore, very few women, for fear of
repercussions, would ever consider making such
a request." (Thomas, G., 1998)

This was reinforced by the comment of one woman:

"Wei, ti'n disgwyl gorfod siarad Saesneg, yn wyt
ti? 'Sdim dewis."

("Well, you expect to have to speak English,
don't you? There's no choice.")

The women on the whole saw themselves a "lucky" or
"fortunate" if they got a Welsh speaking midwife
through the existing system. This again goes contrary
to the principles set out in Changing Childbirth:

"2.2.1 The service will need to be flexible and
responsive to the individual needs of families
being served, and women must be able to
choose who they want to provide their maternity
care."

44

As in the case of health visitors (see Section 7.4.1
above) many of the problems encountered arose from
the simple fact that no one thought to ask the
mother-to-be in which language she would prefer to
speak. In an interview, one father gave a very clear
example of this as he described his experience of
dealing with maternity services:

"Y peth cyntaf sy'n digwydd, mae'n debyg, yw
bod yr Ymddiriedolaeth yn rhoi bydwraig
bersonol i ni. Doedd 'na ddim unrhyw fath o
ystyried anghenion ieithyddol yn rhan o hynny,
felly cathon ni fydwraig ddi-Gymraeg wedi'i
rhoi. 'Oedd hi'n wych o fydwraig, dim cwynion
o gwbl amdani, mae hi wedi dod yn ffrind
personol i'r teulu. Ond pwynt oedd bod dim
ystyriaeth i'r ochr ieithyddol wedi cael ei neud.
Ac wrth gwrs unwaith mae'r person yn troi fyny
ar y drws, fedrwch chi ddim yn hawdd iawn
wneud dim byd amdan y peth wedyn."

("The first thing that happens, it seems, is that
the Trust gives you a personal midwife. There
was no consideration of any kind of language
needs, so we were given a non-Welsh speaking
midwife. She was an excellent midwife, I have
no complaints at all about her - she's become a
personal friend of the family. But the point was
that no consideration was given to the language
side of things. And of course once someone
turns up at the door, you can't easily do
anything about it then.")

As in the case of health visitors, when a non-Welsh
speaking midwife comes to the house, the Welsh
speaking mother or family have a simple choice
between accepting her unquestioningly or facing the
possibility of a personal confrontation on the
doorstep by turning her away. This could be avoided
if maternity care providers were prepared to ask
mothers about their language choice before allocating
them a midwife. In order to do this, providers would
have to acknowledge the importance of speaking
Welsh as one of the professional skills midwifes may
use when dealing with pregnant women.

By not allocating Welsh speaking midwifes with
Welsh speaking pregnant women, one of the key
communication skills of bilingual midwifes is being
wasted. If Welsh speaking women are obliged to
accept the services of non-Welsh speaking midwifes,
it seems likely also that a number of bilingual
midwifes are being allocated to monoglot English
women who have no need of Welsh language
provision which they cannot take advantage of. One
of Gwenan Thomas' recommendations was made on
the basis of her having a "named midwife" who

WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

speaks the same language. In order to be realistic, this
option will have to be offered to women in a way
which makes it totally clear that it is in no way
"special treatment", and that the service provider in
no way regards offering such an option as an
inconvenience or a burden. It will not always be
possible to offer a Welsh speaking midwife to every
Welsh speaking mother, but the present situation
could be considerably improved upon simply by
recognising language as one of the key factors to
consider when allocating midwifes to pregnant
women. It would then be possible to act on the basis
of the recognition wherever that is practical.
Interestingly, Gwenan Thomas research shows that of
the 52 midwives and auxiliary nurses working in
maternity services in the region studied, 27 speak
Welsh, representing 51.9 % of the total. This
corresponds fairly well to the percentage of Welsh
speakers in the general population of
Carmarthenshire, 54.8%, suggesting that it would be
possible to go quite a way towards meeting the
linguistic needs of pregnant women in the area on the
basis of the present level of Welsh speaking staff.

All this is wholly consistent with the principles set
out in Changing Childbirth, for the planning of
maternity services:

Chapter 3 Accessible Care, Sub-heading 3.1 Assessing
Local Needs

"3.1.2 The [Expert Maternity] Group believes
that local population profiles should be refined
so that the purchaser can accurately assess the
characteristics of the child-bearing population.
For example, the ethnic mix and the number of
teenage, unsupported, homeless, or older
mothers will need to be assessed. Purchasers
should ensure that services specifications reflect
any particular needs identified." (In the context
of the National Health Service, local Health
Authorities are the "purchasers", and Trusts and
practitioners such as GPs are the "providers").

7.6 Independent Practitioners - General
Practitioners (GPs), Dentists and
Pharmacists

Of all sections of the National Health Service in
Wales, it is probably here that the Welsh language
provision is at its most ad hoc and inconsistent.
According to the evidence collected from consumers,
the ease or difficulty with which one can find a
bilingual GP, dentist or pharmacist is determined to a
large extent by where you live and whom you know.

The nature and extent of Welsh language provision
among independent practitioners is very difficult to

measure because there are so many pharmacies, GP
surgeries and dental surgeries throughout Wales.

In addition, the status of these independent
practitioners, in relation to the Welsh Language Act,
is unclear and there is uncertainty about whether or
not the situation will change after the formation of
Local Health Groups.

The Health Authorities have committed themselves in
their Welsh language schemes to encourage, support
and facilitate the use of Welsh by these practitioners
in their delivery of health services. It is not yet clear,
however:

1 To what extent the Health Authorities have
been implementing these commitments and
how successful they have been;

2 What expectations the Authorities have in
relation to the use of Welsh by practitioners;

3 What influence the Authorities have on this
matter in practice.

There can be no doubt that this is an area that needs
some immediate attention. This is the sector with
which most consumers have contact and present
inconsistencies and deficiencies mean that there is a
big gap in Welsh language provision within the health
service.

7.6.1 General Practitioners

General practitioners are the first and most important
point of contact with the NHS for a large number of
patients. Very often, it is in the GP's surgery that the
contact between the individual patient and the Health
Service is at its most personal and sensitive. Looking
at the work of GPs is therefore an essential part of
any health care for Welsh speakers. Since the contact
between the GP and the patient is so close and
personal, the importance of language cannot be
denied. In an interview, one former GP described the
reaction of a number of his new patients when he
took over from a retiring local GP in a traditionally
Welsh speaking area. Upon meeting their new doctor
for the first time, several patients expressed their
great relief that he could speak Welsh.

Since they are so numerous, and their surgeries so
widely scattered throughout Wales, it is extremely
difficult to carry out any kind of representative
research into the role of GPs in Welsh language
provision in the field of health care and into their
attitudes towards the Welsh language. What little
evidence was collected strongly suggests receiving
service from your GP in your chosen language is
something which still very much depends on a
number of accidental factors, especially where you

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

45

Chapter 7- Discussion Topics

live. In the most strongly Welsh speaking areas of the
north-west, it is fairly easy to find a Welsh speaking
GP, or at least to find a practice where there is at
least one Welsh speaking doctor. Moving into the
more linguistically mixed regions of the north-east
and mid Wales, it is increasingly necessary to depend
on word of mouth information about which doctors
speak Welsh. In the south-east, a determined and
purposeful hunt is required in order to find a Welsh
speaking GP, and even where Welsh speaking doctors
are available, their language skills are not generally
advertised.

Lists of Welsh speaking GPs and dentists are available
from Bro Taf and Gwent Health Authorities (including
also pharmacists and opticians in the case of the Bro
Taf list). In addition to this, every Health Authority
publishes a list of GPs in the Authority area,
describing their particular skills, including language
skills, in addition to their gender etc, and these lists
are available in public libraries. If the consumers
interviewed are typical of the general population, very
few people are aware of the existence of such lists or
know whereto find them. If such lists are not better
advertised, those who wish to find a Welsh speaking
GP will be obliged to continue depending on word of
mouth and local knowledge. This may work perfectly
well for some people, but it can prove exceptionally
difficult in areas such as Gwent and Glamorgan where
the Welsh speaking population is dispersed and
individual speakers often have little regular contact
with other Welsh speakers.

Even if GPs don't speak Welsh, there are a number of
other things that can be done to show sensitivity to
the needs of Welsh speaking patients, for example:

• M aking sure that bilingual staff are available
at surgery receptions;

• Ensuring that bilingual posters and leaflets are
displayed;

• Providing bilingual forms;

• Noting language preferences when referring
patients to hospitals or social services

Another point which came up during research is that
surgeries where Welsh speaking doctors work need to
be ready to deal with Welsh speaking patients and
make arrangements for them. For example, one
person described how he visited a surgery where he
knew there was a Welsh speaking doctor in order to
register. He explained to staff that he was keen to
register with a Welsh speaking doctor, but staff
refused to register him with this particular doctor,
claiming that he had to register with the practice as
whole. In addition to this, he was warned that he

could not be certain of seeing the Welsh speaking
doctor every time he wanted to unless he was willing
to wait longer than usual. This person did not feel
that the reception staff had any kind of understanding
or sympathy for his situation, and he left the surgery
feeling "hollol wirion. Debyg bod nhw'n meddwl mai
rhyw fath o activist dw i, sy'n creu stwr am y
Gymraeg ymhob meddygfa yn [y dre]." ("Totally
stupid. They probably think I'm some sort of activist,
who kicks up a fuss in every surgery in [this town].")

7.6.2 Pharmacists

Since a substantial number of people often approach
their pharmacist first of all for basic health advice,
there is a definite need to look carefully at the part
played by these key practitioners in Welsh language
provision. In the statistical year 1996-97, more than
37 million prescription items were dispensed by
pharmacists in Wales - an average of 12.2 for each
person in the country - and it is clear, therefore, that
pharmacists are one of people's main points of
contact with the Health Service. (Welsh Office, 1997).
As in the case of GPs, it did not prove possible to
carry out detailed research into the work of this group
of practitioners, and much more research work is
needed before any definite conclusions can be drawn.

Interestingly, the survey conducted by Beaufort
Research for this report showed that Welsh speakers
are more likely to use Welsh with their pharmacist
than with their GP or when attending hospital. 43%
of respondents said they usually spoke Welsh when
using their local pharmacy, compared with 33% who
usually used Welsh with their GP. Of the people who
had received treatment in hospital, only 19% said
they would usually use Welsh when doing that. All
this strongly suggests that Welsh speakers are very
willing to use Welsh when discussing health matters if
they have clear opportunities to do so.

7.6.3 Dentists

The contact that dentists have with the public is not
normally as regular as that of GPs and pharmacists.

On the other hand, that contact tends to be at its
most frequent during childhood and old age, when
many consumers are at their most vulnerable. A
dental surgeon in a hospital sometimes undertakes an
operation that affects the shape and look of a face,
and where great sensitivity and communication is
needed to ease the patients worries.

It did not prove possible to carry out detailed research
into the work of dentists in Wales, and a great deal
more research is required before drawing any
conclusions. It is acknowledged that there is a serious

46

WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

shortage of dentists in Wales, and that most patients
are glad to find any sort of dentist who accepts NHS
patients, let alone find one who speaks Welsh as well.

7.6.4 Opportunities for Independent Practitioners to
Learn Welsh

A substantial number of staff who provide health care
needs in the community have taken steps to learn
Welsh and to use it in their work. But one basic
problem which has arisen because of the position of
GPs, dentists and pharmacists as independent
practitioners within the NHS is that they have to
make their own arrangements for learning Welsh,
unlike many staff within NHS Trusts who often have
classes arranged for them. According to Dr Chris
Walker, a GP who started learning Welsh after moving
from England to Anglesey, more doctors would be
more willing to attend Welsh language courses if it
weren't for financial and time pressures:

"There is plenty of encouragement for hospital
doctors to learn Welsh in terms of study leave
and so on, but GPs have to make their own
plans." (Clark, L., 1997)

Considering the frequent and personal nature of the
contact GPs, dentists and pharmacists have with the
public, it is certainly worth considering how they
could be better assisted to gain the language skills
that would enable them to better provide for Welsh
speaking consumers.

7.7 Accident and Emergency Services -
Ambulance and Paramedical Services

During the research for this report, three main issues
arose specifically related to emergency ambulance
services in Wales:

(i) The importance of employing ambulance drivers
and paramedics who can deal with Welsh
speaking emergency patients in their first
language.

(ii) The extent to which one should expect the
ambulance service to be able to deal with
emergency telephone calls in Welsh.

(iii) The importance of local geographical knowledge
and sufficient understanding of the Welsh
language to be able to record Welsh place names
with complete accuracy and to pass that
information on just as accurately and correctly.

These three questions will be looked at one at a time,
although they are to a large extent bound up with
each other:

(i) Questions regarding the importance of
employing bilingual staff are equally relevant to
the ambulance service as to any other part of
the NHS, and possibly more so since ambulance
crews often come into contact with patients
soon after they have suffered a severe trauma,
such as a road accident. In such circumstances it
may be extremely comforting for some to be
able to converse naturally in his or her first
language.

As in all other parts of the Health Service, the
problems of recruiting skilled bilingual staff to
some jobs have to be acknowledged. Ideally, any
vacant posts will be filled by suitable staff who
are drawn from the local community and so
know the area and its needs, and problems are
likely to arise if bilingual staff from other areas
are brought in, on account of their lack of local
geographical knowledge.

(ii) Another equally difficult to solve question is to
what extent one should expect the ambulance
service to be able to deal with emergency phone
calls in Welsh. As one might expect, the vast
majority of emergency callers do use English
when phoning for an ambulance. However, in
this as in every stressful and painful situation,
there are a substantial number of Welsh speakers
who would choose to convey the relevant
information in their first language if given the
chance.

Up until 1 April 1998, when all of Wales' regional
Ambulance Trusts were merged into a single body
covering the whole of Wales, only one of the then
existing Trusts - the North Wales Ambulance Trust -
had prepared a statutory Welsh language scheme.

That particular Scheme did include a clear
commitment to deal with emergency calls which came
in in Welsh in the same language:

"The Central Control Room which receives
emergency '999' calls will adopt a team
approach to dealing with emergency calls in
Welsh. Arrangements will be made to deal with
Welsh speaking callers."

Information has also been obtained that the
former West Wales Ambulance Trust was
operating an equivalent policy of keeping at
least one Welsh speaker on duty in the Accident
and Emergency Control Room at all times to
respond to emergency calls in Welsh. The new
all-Wales Trust published its draft Welsh
Language Scheme in March 1999. This draft
Scheme states that "the Control Centres that

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

47

Chapter 7- Discussion Topics

receive emergency 999 calls will adopt a team
approach to dealing with emergency calls in
Welsh". In response to an enquiry, a
spokesperson for the new Trust said that the
ability of its Control Centres to deal with calls in
Welsh was "extremely limited", apart from the
two Control Centres in Caernarfon and Rhyl, on
account of the difficulty of recruiting Welsh
speaking staff elsewhere. At present, the extent
of Welsh language provision in the various local
Control Centres is a more or less accurate
reflection of the linguistic make-up of the
communities their staff are drawn from, and so
is very inconsistent from area to area. It seems
likely that improved technology and networking
Control Centres will enable staff in Centres
where there are no Welsh speaking staff to
transfer calls to other Centres where Welsh
language calls can be received. However,
another factor which has to be considered is the
difficulties which could arise from transferring a
call, for example from Pontypool to Caernarfon,
on account of the local geographical knowledge
required to direct an ambulance correctly to its
destination (see point (iii) below).

(iii) The question of ensuring adequate local
geographical knowledge and sufficient
understanding of the Welsh language to record
place names correctly is an entirely practical
one, and is to do with the operation of an
effective service which responds effectively to
patients' needs. This is particularly relevant to
rural areas where houses can be inaccessible and
difficult to locate, and direction signs are
sometimes scarce.

Evidence was collected from two areas in Wales that
ambulances have reached their destination late either
because of a lack of local geographical knowledge, or
because of an inability to deal with Welsh place
names. In one particularly worrying case, it was heard
that a patient's life had been put in serious danger
when a non-Welsh speaking telephonist mistook the
Welsh house name "Wern" for the English number
"one". Since there was no house with the number one
on the street where the caller lived, vital time was
wasted as the ambulance drove up and down the
street looking for a non-existent house. It seems that
the ambulance crew eventually found the house by
asking a local resident who was able to clear up the
confusion between "Wern" and "one". The patient
described in a interview how he had been lying half¬
conscious on the floor and had heard the ambulance
siren go past several times.

"Wn i ddim faint o amser aeth heibio, ond i fi
roedd fel hyd dragwyddoldeb, cyn i'r ambiwlans
stopio'r tu alIan i'r ty."

("I don't know how much time went by, but to
me it was like eternity, before the ambulance
stopped outside the house.")

He went on to claim that he had suffered permanent
damage to his heart, although this could not be firmly
attributed to the long wait before the ambulance
arrived.

As in all parts of the National Health Service, it is not
necessary for all members of staff to become fluent in
Welsh. However it is clear that there are some workers
for whom a basic understanding of some elements of
the language is essential in order for them to carry
out their duties properly, and amongst these workers
are those who are responsible for recording and
transferring important information about patients. If a
patient has a Welsh name or address, it is wholly
unacceptable if it cannot be recorded correctly. Only a
little language training is required to make sure that
key staff are familiar with spelling and pronouncing
the Welsh names they come across.

The question of local geographical knowledge is not
one which is confined to Welsh place names either.
Paul Flynn M ,P, recently drew attention to cases of
confusion where ambulances had been sent to
Newport, Pembrokeshire, instead of Newport, Gwent,
two towns with the same name but around a hundred
miles apart. As ambulance services are centralised,
serious consideration has to be given to the
implications of controlling ambulance services from
outside the areas they are operated in.

(Flynn, P„ 1998)

7.8 Non-clinical Matters

During research, a number of aspects of health care
were looked at which do not pertain directly to the
work of medical and nursing staff, but which are in
spite of that, very relevant to any discussion about
the Health Service in Wales. These are concerned with
permitting patients who are staying in hospital for
any period of time to continue as much as possible
their normal intellectual, cultural and religious
activities.

A long stay in hospital is a monotonous and fairly
boring experience for many people, and because of
this the provision of some means of passing time
pleasurably in the patient's chosen language is
extremely important. The way in which many patients
said they felt "mwy cartrefol" ("more at home") when
able to speak Welsh with staff was described above in

48

WELSH IN THE HEALTH SERVICE:

Chapter 7- Discussion Topics

Chapter 5 - The Language of Medicine, and the same
is true to a certain extent as regards opportunities to
watch television, listen to the radio or read
newspapers and magazines. This matter was referred
to specifically in the 1975 Welsh Office Circular on
the Welsh language in the Health Service:

"With the increasing development of specialist
services at selected hospitals there are few major
hospitals in Wales which do not treat some
patients who will be put more at ease by a
conversation in Welsh or by listening to Welsh
radio or television programmes."

Further on in the same document it is stated:

"Facilities should be provided for patients who
wish to receive Welsh language broadcast
services and to attend religious, cultural and
leisure activities organised through the medium
of either language according to demand."

7.8.1 Radio and Television, Magazines and
Newspapers

A number of NHS Trusts do specifically acknowledge
in their Welsh Language Schemes that they do have a
responsibility to ensure residential patients' access to
Welsh language radio and television channels: and in
two Welsh Language Schemes specific mention is
made of the need to provide such things as books,
audio and video tapes, and children's toys and games
in the patients' chosen language. The question of
providing Welsh language television is not always a
simple one, especially if there is only one television
set available to a large number of patients, many of
whom may not want to watch Welsh language
programmes. Radio is a simpler matter, since patients
can listen to it through headphones. Regarding this,
in addition to ensuring that Welsh language radio
stations such as Radio Cymru can be received,
attention needs to be given to the question of how
many Welsh language programmes it is practical and
desirable to broadcast on internal hospital radio
stations.

There is a need also to ensure that Welsh language
periodicals, such as Golwg, Yr Herald Cymraeg and Y
Cymro, are easily available in hospital shops and on
the trolleys which are taken round the wards. During
observation work, in only one hospital of the seven
visited were Welsh language periodicals available and
on display in the shops provided for staff, patients
and visitors. Without further research, it is not
possible to say if the situation is any better as regards
trolley services to wards.

7.8.2 Religious Provision and Chaplaincies

After serious questions arose during one interview
about the lack of a Welsh speaking medical chaplain,
the main religious bodies dealing with the provision
of Catholic and Protestant chaplains in Welsh
hospitals were contacted.

The two quotations below show how important Welsh
language provision in this field can be to some
patients. One comes from a chaplain, the other from
an experienced doctor:

"Dwedwch bod chi'n Eglwyswr neu efallai'n
Ymneilltuwr clasurol Cymraeg, a chithau ar eich
awr olaf, mi fyddai fo'n drwsgl pe byddech chi'n
cael rhywun oedd ddim yn medru'r Gymraeg."
("Say that you're an Anglican or maybe a classic
Welsh speaking Non-conformist, if you were at
death's door it would be awkward if you were to
have someone who didn't speak Welsh.")

"Mae 'na ddigon o bobl yng Nghymru sydd yn
byw eu bywyd bob dydd trwy'r Saesneg ond
bod eu profiad ysbrydol nhw yn gwbl uniaith
Gymraeg... A dyna pam mae llawer o bobl yn
gwybod bod Duw yn siarad Cymraeg, bod Duw
yn siarad Wrdw, Swahili a Hindi a falle bod e'n
siarad Saesneg ond dyn nhw mor sicr. Falle bod
e, ond dyn nhw ddim yn siwr. Mae'r cyd-destun
ysbrydol i gyd yn yr iaith Gymraeg."

("There are plenty of people in Wales who live
their every day lives in English but their
spiritual experiences are completely monolingual
Welsh... And that's why a lot of people know
that God speaks Welsh, that God speaks Urdu,
Swahili and Hindi and maybe he speaks English
but they're not so sure about that. Maybe he
does but they're not sure. The spiritual context
is entirely in the Welsh language.")

Like most other National Health Service staff, hospital
chaplains are salaried Trust employees, and when
researching into any shortage of Welsh speaking
chaplains, the same two challenges are faced as when
looking, for example, at the shortage of Welsh
speaking doctors:

(i) To ensure that enough qualified Welsh speakers
apply for posts when they become available.

(ii) To ensure that NHS Trusts acknowledge the need
for Welsh speaking chaplains and act on the
basis of that acknowledgement by

(a) either appointing bilingual chaplains.

(b) or assisting non-Welsh speaking chaplains
to master the language.

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

Chapter 7- Discussion Topics

(c) or making sure that it is possible to find a
Welsh speaking chaplain quickly and easily
when one is required.

Points (ii)(b) and (ii)(c) are particularly relevant to
full-time chaplains; in the case of part-time chaplains
there is more room for flexibility and for the use of a
team dimension to ensure that Welsh language service
is available for those who want it. According to a
spokesperson for the Union of Welsh Baptists, some
non-Welsh speaking chaplains already do this
informally by appointing a Welsh speaking minister
to take a few sessions in the hospital. In the same
way, an Anglican priest described how he is
occasionally called into his local hospital:

"Dw i'n cael achlysuron yn codi lie y dw i'n cael
galwad ffon yn hwyr y nos neu'n gynnar y bore,
a "Look, we've got a Welsh speaker, can you
come in and do last rites," neu "Can you come
and talk to them." A dach chi'n falch o neud,
felly, ond mater o hap a damwain ydy o."

("I get occasions arising where I get a phone call
late at night or early in the morning, and they
say, "Look, we've got a Welsh speaker, can you
come in and do last rites?" or "Can you come
and talk to them?" And you're glad to do it, but
it's a matter of chance.")

According to a spokesperson for the Catholic
Archdiocese of Cardiff, although there is not a single
full-time Welsh speaking Catholic chaplain in any
hospital in Wales, there is a substantial pool of
bilingual priests and nuns who are ready at any time
to visit patients. According to the spokesperson, it is
NHS Trusts which bear the main responsibility for
ensuring religious provision for Welsh speaking
patients: "The crucial thing is that the hospital makes
sure that a priest, or anyone who can speak the
language, is contacted."

A letter to the Church in Wales enquiring about Welsh
speaking Anglican chaplains was passed on by the
Church to the Managing Trust Chaplain of the
University Hospital of Wales, Cardiff. He had no
comment to make on the subject of Welsh language
for patients and referred the author to the Trust's
Welsh Scheme, stating that "the matter of providing
appropriate support for patients through the medium
of Welsh is a matter for the Trust who is the employer
and not the Church." In response to this, it should be
noted that neither University Hospital of Wales' Welsh
Language Scheme nor the equivalent Scheme of any
other NHS Trust, have anything to say specifically
regarding chaplaincy services, apart from general
statements about ensuring appropriate levels of Welsh
speaking staff.

The key point when looking at the provision of Welsh
speaking chaplains is the same key point as when one
looks at any other aspects of Welsh language
provision in the field of health care, namely that a
Welsh language service should be offered as a norm
without the patient having to make a special request
or pressurize the service provider in order to receive
it. As in all other parts of the Health Service, making
sure that a Welsh speaking patient can see a Welsh
speaking chaplain if he or she so wishes, depends on
an effective set-up to record language choice, to pass
that information on as the patient goes through the
system, and to act on the basis of the information as
far as possible. This is particularly important when
one remembers that many people request the services
of a chaplain during their final illness, when they are
at their most vulnerable and helpless.

7.9 The Trouble with Forms

Although every Welsh Language Scheme prepared by
health care bodies in Wales contains a commitment to
provide Welsh language forms, problems are still
occurring in connection with some forms. This seems
to be due to two main factors:

(i) Although there is an official commitment to
produce Welsh language forms, the production
process has not yet been completed (possibly
because of technical difficulties). For example, in
the case of prescription forms, the Welsh Office
has stated that the machines presently used to
produce the forms do not allow the printing of
bilingual text, although it is intended to remedy
this at some point in the future.

(ii) Although Welsh forms are available, staff are
not aware of their availability and do not know
where to find them. This is especially true of
large and bureaucratic organisations where
information is slow to circulate, but can occur
even within individual offices where not all staff
are aware in which cupboard Welsh language
materials are kept. In addition to this, there is a
substantial body of anecdotal evidence that
Welsh language letters and forms are being
ignored by a number of public bodies because
individual staff do not know what to do with
them. In interviews, more than one patient
complained that he or she had been given
bilingual forms in hospital but had been urged
by Welsh speaking staff to fill them in in
English because there was a danger they would
not be properly processed if completed in Welsh.
It is clear in this regard that there is a need to
raise staff awareness, both among Welsh

50

WELSH IN THE HEALTH SERVICE:

Chapter 7- Discussion Topics

speakers and non-Welsh speakers, about which
things are available to consumers in Welsh, and
about what one should do when a client fills in
a form in Welsh,

The situation is at its most problematic in the case of
forms used for patients to consent to undergoing
surgery, This issue was raised in the 1975 Welsh
Office Circular on the Welsh language in the Health
Service:

"The Secretary of State has decided that
'Consent to Treatment' forms, which have to be
completed by patients, should be bilingual."
(Swyddfa Gymreig, 1975)

In spite of this, two major complaints are still arising
in connection with this type of forms:

(i) That they have to be specially requested, and are
sometimes stored inconveniently and separate
from the equivalent English forms.

(ii) That some doctors are refusing to sign them if
they are filled in in Welsh only, and are insisting
that patients who wish to fill in the Welsh
version also fill in the English version. The
reason usually given for this is that non-Welsh
speaking doctors are unwilling to accept
responsibility for treatment by signing a form
they don't understand.

In an interview, the above two points were raised
together by one patient:

"Ffurflen uniaith Saesneg. Ddaru mi ofyn am un
Gymraeg. Wei, yr argraff bod chi'n creu fuss i
ddechrau. Wedyn oeddan nhw'n ffonio rownd,
ces i'r argraff bod nhw'n ffonio rownd y
wardiau eraill i ofyn os oedd ganddyn nhw gopi
o'r ffurflen yna. Tua ugain munud neu hanner
awr wedyn, ddaru nhw ei ffindio fo. Oedd y
meddyg wedyn yn gwrthod llofnodi'r un
Gymraeg... oni bai mod i hefyd yn llofnodi'r un
Saesneg."

("Monolingual English form. I asked for a Welsh
one. Well, first of all there's the impression that
you're making a fuss. Then they phoned round, I
got the impression they were phoning round the
other wards to ask if they had a copy of the
form. About twenty minutes or half an hour
later, they found it. The doctor then refused to
sign the Welsh one... unless I also signed the
English one.")

Although doctors' anxieties in this regard are entirely
understandable, there should be no problem if a
patient signs a Welsh form, or the Welsh side of a
bilingual form, provided there is something on the

Welsh document noting in English that it is an
official and authorised translation of the equivalent
English document. It is perhaps worthwhile referring
at this point to the Welsh Blood Service as an
example of a health care establishment which has
taken steps to ensure that all its leaflets and forms are
bilingual, and to make sure that non-Welsh speaking
staff know how to deal with forms filled in in Welsh.
Since the layout of the Welsh and English versions is
exactly the same, and since filling in the forms
mostly involves ticking boxes, they can be easily
checked by staff in whichever language they are filled
in. In an interview, one new blood donor described
his surprise and satisfaction at what happened when
he filled in a Welsh language form and presented it to
a non-Welsh speaking member of staff:

"Fel arfer, dych chi'n disgwyl tipyn o ffws, neu
o leiaf fydd rhaid i chi ateb llwyth o gwestiynau
gwirion am y Gymraeg a pam ych chi'n ei
siarad hi a pethau fel 'na. Ond, na - dim ffws,
dim trafferth, dim cwestiynau dwl, 'Oedd e'n
gret, y fath ryddhad."

("Usually, you expect a bit of a fuss, or at the
very least you'll have to answer a load of stupid
questions about Welsh and why you speak it
and things like that. But, no - no fuss, no
bother, no stupid questions. It was great, such a
relief.")

According to this donor, the bilingualism of the Blood
Service is so thorough that the service's computers are
able to keep records of postal addresses in Welsh,
contrary to the practices of a number of bodies of
translating the information into English even when
the client has given it in Welsh.

7.10 Language, Dialect and Terminology

Amongst the key steps noted in the White Paper
Putting Patients First towards developing effective
systems for sharing health care information quickly,
efficiently and safely, is the need for "a common
language to enable consistent meanings to be
attributed to words, terms and data." (Welsh Office,
1998) Although the White Paper is referring chiefly in
this regard to the need to standardize the Health
Service's English terminology, a number of Health
Care practitioners have referred to the exact same
need in connection with the Welsh language. For
example, in a recent survey of north Wales midwives,
80% of respondents said they considered the creation
of Welsh midwifery terms as either "quite important"
or "very important". (Roberts, G„ 1998)

As in many technical and scientific fields, there has
not been, up until now, any substantial body of

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

51

Chapter 7- Discussion Topics

official Welsh terms for use when discussing health
care. There have been several recent attempts to make
up for this lack of officially recognised terminology:

• In 1986, the University of Wales Press
published Medical Terms.

• In 1995, Termau Nyrsio a Bydwreigiaeth: An
English - Welsh Dictionary of Nursing and
Midwifery Terms was published as a joint
project by two members of the staff of the
University of Wales, Bangor - Gwerfyl Roberts
of the School of Nursing and M idwifery
Studies, and Delyth Prys of the Welsh
Terminology Centre which is part of the
University's School of Education.

• The Welsh Terminology Centre has also
established contact with Termcat - the Catalan
Standardisation Centre in Barcelona - and
with Canolfan Bedwyr, another establishment
within Bangor University which advises
translators on the clarity of official Welsh
documents.

• Also part of the Welsh Terminology Centre's
work has been the establishment of an
electronic discussion group concerned with all
kinds of Welsh terminology, including medical
and nursing terms. This can be reached on the
Internet: http://www.mailbase.ac.uk/cgi-

bin/l ists/welsh-termau-cymraeg.

The discussion group can be contacted by
e-mail: welsh-termau-cymraeg@mailbase.ac.uk

• As part of the Bilingual Initiatives in
Midwifery project at Bangor University's
School of Nursing and Midwifery, a Midwifery
Terms Group has been set up to co-operate
with the Welsh Terminology Centre and with
clinical midwifes. The aim is to secure the co¬
operation of language specialists, computer
specialists, and subject specialists to create a
store of standardised terminology which can
be easily accessed by electronic means. The
Terms Group also maintains contacts at the
NHS Centre for Coding and Classification in
Loughborough, and the possibilities of coding
Welsh terms in order to use them in a
computerised data base, in the same way as is
now done with English terms, are being
looked at.

• During the research for this report, the author
was contacted by Dr Eluned Lee, Medical Co¬
ordinator at the Gwynedd Community Health

Trust Department and Contraception and
Sexual Health, concerning work currently in
progress to create a dictionary of Welsh sexual
health terms. Dr Lee said that the lack of
useful Welsh terms in this field had come to
light during her time as an "agony aunt" for
Cylchgrawn y Cofi Bach, a Welsh language
magazine for young people in the Caernarfon
area.

• The Welsh Academy Dictionary, published in
1995, is always a valuable resource to fall
back on, although its bulk and weight make it
unsuitable for use in many situations.

One consistent factor which has to be faced when
trying to introduce Welsh language terminology to
any field is that consumers are sometimes very
reluctant to adopt it, seeing it as a false and invented
language. Although this is perhaps somewhat
disappointing from the standpoint of developing the
Welsh language and expanding its areas of use, if we
are looking at the question of Welsh language health
care terminology from a consumerist standpoint, then
this situation has to be acknowledged and accepted as
it is, rather than being seen as a problem. As
Dr Dafydd Huws has noted, there are four possible
reasons for providing a service in Welsh:

(i) For the sake of the language.

(ii) For the sake of the principle involved.

(iii) For the sake of the provider.

(iv) For the sake of the consumer.

(Roberts, G., 1997)

If any of the first three of these is considered the
most important, then there is no reason for not
seizing every opportunity to use and disseminate the
new Welsh terminology; but if it is the fourth one
which is uppermost in the mind, then there is a need
for caution. According to the testimony collected in
several areas, one thing that is certain to keep Welsh
speakers from using their Welsh in official and public
situations is the fear that their own Welsh isn't good
enough; i.e. it fails to reach some theoretical standard
of what Welsh should be. An interesting example of
this came up in a number of interviews with health
care consumers, when several people insisted quite
definitely that they found it easier to discuss health-
related matters in English than in Welsh because they
didn't have sufficient vocabulary to talk about such a
subject in Welsh. It became clear through questioning
these people in greater depth that when they said they

52

WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

preferred to use English what most of them actually
meant was that they used a few English words within
otherwise Welsh sentences. This usually happened
when it was necessary to refer to an illness or a form
of treatment by its formal English title, and no
consumers seemed to have any difficulties using
Welsh when it came to describing the symptoms
which they themselves were experiencing. In spite of
this, a number of people saw this sort of speech as
"English". As one experienced doctor noted when
discussing this subject:

"Mae 'na boendod efo Cymry Cymraeg os ydyn
nhw'n defnyddio unrhyw un gair o Saesneg bod
eu Cymraeg nhw ddim digon da."

("There's worry with Welsh speakers that if they
use a single word of English that their Welsh
isn't good enough.")

As described in Section 8.2.1 Producing Bilingual
Material, there is a definite need for new terminology
to be comprehensible and clear. If it is not both of
these things, its use is likely to be confined to a small
number of people who take a special interest in such
things. Terminology must also not become an
additional burden on Welsh speaking patients who are
unfamiliar with it. One thing which is obvious is that
there is a need to increase the confidence of Welsh
speakers in order for them to use their Welsh publicly,
and this will never be achieved unless it is made clear
to people that they are welcome to use whatever sort
of Welsh which is natural to them. The function of
any statutory Welsh Language Scheme is not the
maintenance of the Welsh language in all its spotless
purity: rather, to open the way for consumers to
communicate in their preferred language and at the
level at which they are most comfortable. The natural
lack of confidence which many consumers feel when
using their Welsh in official situations will never be
overcome, if they feel they are being expected to
conform with a style of Welsh which is overly formal
and academic. There certainly is a place for Welsh
terminology in every part of the Health Service, but
only to the extent that it will be of benefit to the
service's consumers.

7.11 Cultural Sensitivity

Although it can no longer be claimed that native
Welsh speakers have a particular characteristic way of
life in any real sense, it is true that there are certain
social practices which are perhaps more obvious in
traditionally Welsh speaking communities than in the
wider non-Welsh speaking society.

The most obvious of these, and particularly relevant
in the field of health care, are greeting and

conversational conventions, especially amongst the
older generation. This point was raised in interviews
by several medical professionals, and also by a
number of ordinary consumers who felt that relatives
of theirs had been treated in an inappropriate manner,
bordering on the insulting, because of a lack of
awareness amongst staff of Welsh greeting and
conversational conventions. The main concern of both
professionals and consumers was the widespread
tendency to use patients' first names when greeting
them and when giving them instructions and
information. Since a good relationship between
patients and the staff caring for them is central to
any successful treatment, it is perfectly
understandable that some staff use patients' first
names as a way of being more intimate with them.

But it must be remembered that what is considered
friendly intimacy in English culture may be seen by a
Welsh speaker as a sign of a lack of respect. It may
appear cold and distant to some that people who have
known each other for many years still call each other
"Mr" and "Mrs", but in reality it is no such thing.

One person described the intense confusion felt by her
mother, already in a fairly confused state and unsure
of who was talking to her, when nurses addressed by
her first name. For many of the older generation, its
is likely that only their siblings and a few very close
friends would be in the habit of using their first
names, and considerable confusion and discomfort
can be caused if someone from outside that limited
group begins to address them in that way. Even
amongst fairly close friends, a substantial number of
people continue to use the titles "M r" and "M rs"
together with surnames, rather than using first names.
On the other hand, for some people the most
acceptable practice is to use a person's full name, e.g.
"Mary Jones" rather than "Mary" on its own or the
formal title "M rs J ones". The one thing which should
be avoided at all costs is the use of first names on
their own, as one health care worker noted:

"Yn arbennig os ydy rhywun yn Gymraeg, os
nad ych chi'n nabod rhywun yn rhyfeddol o
dda, fyddech chi byth yn defnyddio ei enw
cyntaf, byddai 'n sarhad."

("Especially if someone is Welsh speaking, if you
don't know someone extremely well, you would
never use their first name - it would be an
insult.")

Another matter which requires considerable
discernment when dealing with it is the question of
when and with whom to use the pronoun "ti" (second
person singular and informal, equivalent to "thee" in
English and "tu" in French) instead of "chi" (second

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

53

Chapter 7- Discussion Topics

person plural and formal, equivalent to "vous" in
French, and to the original meaning of "you" in
English). On the whole, the conventions regarding the
use of "ti" and "chi" are much the same as those
regarding the use of first names. In the same way that
many people continue to address each other as "M r"
and "Mrs" after long years of friendship, a substantial
number of Welsh speakers adhere to "chi" forms when
speaking to friends, and even to their spouses. In
addition to this, the fact that one participant in a
conversation has begun to call the other person "ti"
does not necessarily mean that that other person may
address the first person in the same way, particularly
if the first is older than the second. J ust like the
greeting practices described above, these practices in
no way indicate coldness or a lack of intimacy, rather
they are conventions based on traditional methods of
showing mutual respect. The quotation below is
drawn from an interview with an elderly consumer,
and clearly illustrates many older people's feelings
about the use of "ti" and "chi":

"Os dach chi'n defnyddio "ti" a rhywun hyn na
chi neu unrhyw un sy'n ddieithr, beth ydach
chi'n neud wedyn ydy mynd i mewn i'w lie
nhw, space mae'r Sais yn alw fo... Dach chi'n
tramgwyddo wrth alw rhywun yn "ti." Baswn i'n
amheus iawn o'i ddefnyddio fo oni bai 'mod i'n
medru ffydd, a maeffydd yn dod rhan amlaf
dros amser. Ac wedyn pan mae'r ddau ohonoch
chi'n teimlo'n gyffyrddus efo ti, 'na fo, popeth
yn iawn. Ond cyn i hwnna ddigwydd mae'n
berygl rhyfeddaf. Mae peth wmbreth o'r bobl
sy'n dysgu Cymraeg i oedolion yn deud wrthyn
nhw, "Ti i bawb," ond mae o'n achosi anhrefn
llwyr, emotional chaos, achos dach chi ddim yn
gwybod sut i ddelio efo fo... Mae pobl yn
dweud, "Mae o'n fwy user-friendly," ond dydy
hynny ddim byd i wneud a fo achos beth sy'
gynnoch i wneud y peth yn user-friendly ydy
cwrteisi naturiol, consyrn am sut mae person
arall yn teimlo."

("If you use "ti" with someone older than you or
someone you don't know, what you're doing
then is going into their space... You offend
someone by calling them "ti." I would be very
hesitant to use it unless I felt confident in doing
so, and that usually comes with time. And then
when both of you are comfortable with "ti",
then it's fine. But before that happens, it's very
risky. Loads of these people who teach Welsh to
adults tell them, "Say "ti" to everyone," but it
causes complete chaos, emotional chaos, because
you don't know how to deal with it...People say,
"It's more user-friendly," but that's got nothing
to do with it because what you need to make the

thing user-friendly is common courtesy, a
concern for how another person feels.")

This can be confusing enough for many first language
Welsh speakers, but it is particularly difficult for those
who are learning the language, largely because in
most regions equivalent forms no longer occur in
English. According to one official with responsibility
for promoting the Welsh language in the field of
health care, this is one of the most important points
which has to be impressed upon Welsh learners in the
field, since many of them to tend to use "ti" when
talking to patients, believing it to be more friendly
and intimate.

Interestingly, Gwenan Thomas' research into the
experiences of pregnant women in the Glangwili
Hospital catchment area showed that some young
women preferred to be greeted with the informal
forms "ti" and "tithau" ("thou / thee also") when
talking to medical staff, and felt that there was a
greater intimacy between themselves and staff after
switching from addressing each other as "chi" to
using "ti":

"Ma "ti" a "tithe" yn dod, wedyn ti'n gwybod fel
ti'n aros yn y berthynas."

("When they start using "ti" and "tithau", then
you know where you stand in the relationship.")

"Pan mae rhywun yn siarad a ti fel "ti", wedyn
ti'n teimlo'n nes ato nhw, dim fel patient ond yn
gyfartal, mwy fel ffrind, dim fel claf."

(Thomas, G., 1998)

("When someone talks to you as "ti", then you
feel closer to them, not like a patient but equal,
more like a friend, not like a patient.")

(Thomas, G„ 1998)

All this strongly suggests that old practices and
conventions of speech which are so important to the
older generation of Welsh speakers are seen as
somewhat cold and distant by some of the younger
generation. However, there is a need for caution, and
the best advice one can give to staff at present is to
stick to a formal greeting unless it becomes obvious
that a patient would prefer to use a less formal
register.

7.12 Spreading the Word - Information Services

"Information is a service in its own right.
Information is essential for people who are
making decisions and exercising responsibility...
And to the extent that the information is good
or bad, is clear or unclear, and is or is not
comprehensive, the options open to people and
the decisions they take will be better or not as
good." (Cyngor Defnyddwyr Cymru, 1995).

54

WELSH IN THE HEALTHSERVICE:

Chapter 7- Discussion Topics

7.12.1 Telephone Information Services

A certain amount of health information is already
available to the public in Wales through the
freephone link Health Information Wales. Through
this service, information is available about which
services the NHS provides; local standards and
performance in reality as measured against them;
waiting times for hospital treatment; and health care
and self-help groups. When this phone service was
used during the research for this report, no Welsh
language service was available, nor was any
information available about Welsh language provision
in the one field which was enquired about
specifically, namely speech therapy.

In J anuary 1998's white paper, Putting Patients First,
and in the follow-up document, Quality Care and
Clinical Excellence, it is stated that consideration is
being given to developing a new 24 hour telephone
help line, building on the basis of Health Information
Wales. According to the White Paper, the Secretary of
State will consider introducing such a system to
Wales after assessing the cost-effectiveness and the
benefit to patients of trials carried out in England. In
March 1998 pilot schemes were launched in 3 regions
in England, with phone lines staffed by nurses giving
professional advice to callers on such questions as
what sort of treatment to seek, as well as providing
information on less urgent matters such as local
waiting times. Especially when one remembers the
important and clinical nature of much of the
information given to consumers through this system,
it will be necessary to consider very seriously the
need to make that information available in Welsh,
and the promise in the Patients' Charter to do that as
far as possible, when planning any such service for
Wales. As one of the most pioneering developments in
the NHS in recent years, NHS Direct is a golden
opportunity to show how Welsh language provision
can be integrated into a comprehensive service to
patients. Within the three pilot schemes in England,
there are already arrangements in place "to ensure
they can deliver advice in a very wide range of
languages." (Welsh Office, 1999)

NHS Direct is also an opportunity to show what can
be done with the latest telephone technology to
facilitate language choice. An operating example of
this is to be found in the phone system of the
National Library of Wales, where a choice of
languages and departments is offered to callers for
them to select from using the buttons on their own
phone. The software for these sorts of systems is
already easily available, and is widely used by a
number of institutions in mainland Europe.

(Detailed information about the results of the NHS
Direct pilot schemes in England is available on the
Internet: http://wwwdoh.gov.uk/nhsexec/direct.htm)

7.12.2 The Possibilities of Radio

Some very interesting research work has recently
been conducted in the Leicester area by Arvind Bhatt
and Professor J ames D. Halloran to assess the listener
response to the radio show Health Matters, which was
broadcast for a limited period by the Sunrise FM
station. Sunrise FM is a station which specialises in
providing music, news and information for
Leicestershire's Asian Community, and it was this
community that was the target audience for the
programme Health Matters. Although the comparisons
between the situation of the Welsh language in Wales
and that of Asian minority languages in England
should not be over-stressed, there are a number of
points which came up in Bhatt and Halloran's
research which is it worthwhile considering.

The programme was established as a joint project
between Leicestershire Health Authority and Sunrise
FM, and amongst the main aims of the project were:

(i) raise awareness about the health care system,
about key health issues, and about patients'
rights.

(ii) advertise local health events and self-help and
discussion groups in Leicester.

(iii) emphasize the importance of Health Promotion.

(iv) encourage consumers to take part in local NHS
planning processes.

A local GP was chosen to be a "Radio Doctor", co¬
presenting the programme with a presenter from the
radio station. A phone-system was set up, and a
system for answering letters. The listeners who
phoned the show would speak a number of Asian
languages to the presenters, a situation which was
facilitated by the relative similarity of Urdu, Hindi,
Gujarati a Bengali. Bhatt and Halloran's research
showed the radio show was particularly effective as a
means of conveying medical information to
vulnerable and isolated consumers who perhaps lack
the confidence or the means to go and see a doctor in
person. There were four main reasons for the
popularity of the programme:

(i) Above all, listeners, especially older listeners,
appreciated hearing about health issues in their
first language:

"Hindi-Urdu was just right for us because we
don't know Englsih very well, and it was nice to

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

55

Chapter 7- Discussion Topics

hear our own language when discussing health
problems."

"We all liked the programmes in my family.
There was lots of information there which we
can understand."

"These are not just important - they are
absolutely vital for older people who do not
understand much - have language difficulties. It
is vital to be able to talk in your own language
You need vital information in your own
language from someone you can trust."

(ii) The privacy and convenience of the radio were
two other things listeners spoke of:

"Radio is portable - you can listen to it
anywhere on your own."

"You can listen in private if you want to, or in
the factory where everyone listens."

(iii) The programme was of help to those who felt
that their local GPs had too much work and too
little time to be able to discuss everything fully
with every patient:

"There is a lot our doctors can't tell us, they
have no time for us."

"I don't like going to the doctor unless I am
very ill and then he has not got much time for
you. He can't give you all the information, but I
can listen to the radio and get more
information."

(Notice in the second quotation above that the
respondent sees the radio as a source of "more
information", i.e. the radio had not replaced the GP as
a source of information, rather the information from
the radio complements that from the doctor).

(iv) The confidentiality of the phone-in section of
the programme was appreciated:

"Phone-in was good - keep that. We can learn
more from other people's problems if we are too
shy to ask ourselves."

"Phone-in was good. I could listen to my
own probelms without having to ask in
public."

"Phone-in can be more confidential. You can
do it there and then on your own."

These comments are particularly relevant when
considering some types of illness, such as mental
illness, which still have a social stigma attached to
them.

A number of the listeners who took part in the
research asked for more follow-up to the programme,
wanting things such as leaflets in Asian languages to
be available in places such as local libraries and
doctors' surgeries. It is clear therefore, that there is a
possibility of conducting a multi-media programme of
health promotion in Leicester's Asian community
using radio and printed material to back each other
up.

56

WELSH IN THE HEALTHSERVICE:

Chapter 8 - IMAGE AND SUBSTANCE

8.1 External Corporate Image

In accordance with Welsh Language Board guidelines,
all Health Authorities and Trusts in Wales either have
already or are currently taking steps to adopt a
bilingual corporate image. This is a development
which is very much to be welcomed, since it gives
status and public prominence to the Welsh language,
and because it creates a feeling amongst consumers
that the establishment in question is one which
accepts the language. The second of these two points
was acknowledged as early as 1975 in the Welsh
Office Circular on the Welsh Language in the National
Health Service (see Section 6.2 above):

"As the language of the inquiry is directly
influenced by the environment in which it is
made, every effort should be made to encourage
the use of Welsh by exhibiting signs and notices
in both languages in reception areas, giving
them equal status, and on all main external and
main internal signs and on vehicles."

(Welsh Office, 1975)

The definition of a bilingual image has since been
expanded to include much more than signs on walls
and vehicles, being extended to include such things
as the establishment's logo, staff badges, headed
paper and business cards. Although these are
superficial things, there is clear evidence that they are
appreciated by the Welsh speaking public, particularly
in regions where Welsh has been traditionally almost
entirely exiled from public life.

As part of the research for this report, observation
work was carried out in seven of Wales' general
hospitals, looking amongst other things at the
following aspects of external image:

(i) The frequency, quality and clarity of
bilingual signs

(ii) The bilingualism of pamphlets and
leaflets available to patients

(iii) The bilingualism of posters and
notices on noticeboards

(iv) The visible and practical
bilingualism of main reception areas

(i) The most striking things when assessing the
visible bilingualism of hospitals are the large
variances which are to be found even between
institutions in the same area. For example, when
visiting two fairly adjacent hospitals, it was
noted that whilst clear and readable bilingual
signs were to be found in almost every part of
one of the two, the other contained a large
number of monolingual English signs. This

second hospital was the only one visited which
did not have standard bilingual direction signs
to departments. Surprisingly, this hospital was
also the one with the newest-looking signs,
especially when one remembers that bilingual
signs have been in place in some hospitals in
the same area for many years. It is disappointing
to note that the management of this particular
hospital seem to be showing a decreased
awareness of the importance of bilingualism,
just as the rest of Wales is coming increasingly
to recognise its value.

One thing which was consistent between all but
one of the seven hospitals looked at was that all
signs giving warnings or instructions were in
English only. There was also a general tendency
for temporary signs and hand-written signs to
be in English only. Amongst other examples
noted of poor quality signage was the large
bilingual sign placed outside one hospital
showing the name of the establishment - the
sign was divided into two parts, with the Welsh
section facing away from the path so that one
had to walk over on to the grass to read it
properly. In the same hospital, the Welsh was
below the English on all signs, and so close to
the floor in some places that it was very difficult
to read them. These are both examples of the
iconic use of Welsh, without sufficient thought
being given to the practical usefulness of the
materials produced. Of the six hospitals where
site maps were seen on the walls, four had maps
in English only.

(ii) As regards pamphlets and leaflets, there was a
great deal of variety and inconsistency from
place to place, even within individual hospitals.
Particularly disappointingly, in one hospital a
special display stand was found in the centre of
the main reception area full of monolingual
English Social Security pamphlets, including a
substantial number which are normally provided
bilingually. At the other end of the spectrum, in
one hospital, a comprehensive exhibition of
health information leaflets was found, the
contents of which was all either bilingual or
displayed with English and Welsh versions of
documents easily available side by side. In most
other establishments, there was usually a variety
of English, Welsh and bilingual leaflets, with the
majority being in English only. Interestingly,
there was no obvious system either for the
displaying of leaflets in other minority
languages. For example, in one hospital there
was one leaflet in Gujarati about a very

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

57

Chapter 8- I mage and Substance

particular kind of benefit payment, but no other
material at all in the language or in any other
Asian language. It seems clear that accident and
whim are still the main factors controlling
which documents are distributed in which
languages in many hospitals.

(iii) In all but one of the seven hospitals, posters on
noticeboards tended to be in English only,
although the fact that bilingual posters were to
be found in one hospital does suggest that
bilingual material is available if a genuine effort
is made to obtain it. Where job vacancies were
advertised, advertisements tended to be in
English only in all but one hospital.

(iv) There was nothing in any of the hospitals to
suggest whether one could expect to receive
assistance in Welsh from staff on the main
enquiries desk, meaning that consumers are
obliged to depend on such things as accent and
names to identify Welsh speaking staff. For
example, in one hospital the receptionist was
wearing a monolingual English badge, and it
was only the fact that she had a particularly
Welsh-sounding name which suggested that she
could speak Welsh. In two of the seven
hospitals, it was possible to get an intelligible
response in Welsh to enquiries in Welsh, and the
receptionists in three others seemed to
understand Welsh to a certain degree but
responded either in English or by gesturing with
a hand towards the location of the thing
enquired about. In the other two, enquiries in
Welsh elicited the following responses:

"I'm sorry?"

"What?"

Although the above is important, it must be noted
that bilingual corporate signs are not enough for
customers. This point was raised in 1996 in the report
'Welsh as a Consumer Issue 1 :

"Language as a symbol and icon has become
more important than language as something that
is used. The bilingual letterhead and a few token
words of Welsh greeting at reception are
welcome whenever they are found. But these
tokens and emblems of Welsh identity should
not be mistaken for bilingualism, or for the kind
of practical approach to language and its use
that the consumer needs". (Welsh Consumer
Council, 1996)

These comments were supported more recently by Dr
Colin Williams:

"Superficial, patina or a political, correctness
bilingualism is what we get practically from
agencies and organisations everyday.

(Williams, C. & EvasJ, 1997)

If there is no bilingual provision by a public bilingual
face, then Welsh speakers will be disappointed and
disillusioned:

"The Welsh Consumer Council recognizes the
importance of Welsh as a token and icon of
identity, community and nation. But we call on
all those involved to recognise that practical
Welsh language policies must be more than
symbols. Welsh must also be usable.

Frameworks, opportunities, rights and contexts
must be clear." (Welsh Consumer Council, 1996)

8.2 Written Welsh

8.2.1 Producing Bilingual Material

"Cyfieithiad clogyrnaidd o eiriau, o sillaf i sillaf,
yn hytrach na geirlun neu Gymreigiad o'r
pethau a ddynodant."

("A clumsy translation of words, syllable by
syllable, rather than a picture in words or an
expression in Welsh of the things they denote.")
Plicio Gwallt yr Hanner Cymry, Emrys ap I wan,
1889.

Although written over 100 years ago, the comments
of Emrys ap Iwan on poor quality translation are still
very much relevant. They were reiterated somewhat
more recently by Professor Colin Williams of Cardiff
University:

One of the reasons that individuals don't use
Welsh forms is that they can be
incomprehensible! Too often, people are obliged
to turn to the English version for an
explanation. The words are correct, but because
they are a translation, the concepts and the style
are not user-friendly, and worse than that they
don't attract people to use [the forms]. We need
to simplify the language of documents and make
it more natural, and maybe rather than
translating them from English rewrite them in
order to make the Welsh more attractive. It's
important that we start pressing for professional
bilingual provision in user-friendly language."
(Williams, C. & Evas, J., 1997)

A similar verdict on poor quality translation is to be
found in Arvind Bhatt's booklet on translating health
information, Many Voices, One Message, published by
the Health Education Authority in 1997:

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WELSH IN THE HEALTHSERVICE:

Chapter 8- I mage and Substance

"Too much concern with linguistic accuracy and
faithfulness to the original could lead to
unreadable translations... An easily
comprehensible text is more likely to be
accepted and will be read more widely than an
obviously translated text." (Bhatt, A. 1997)

Although leaflets and forms are now available in
Welsh from a large number of public bodies in Wales,
a substantial section of the Welsh speaking
population continues to favour those produced in
English. In the case of some people, this is simply a
matter of habit or lack of information about what is
available, but one cannot ignore the fact that many
fluent Welsh speakers choose to use the English
versions of some official documents because the
Welsh ones are unreadable. For example, the NOP
survey conducted on behalf of the Welsh Language
Board in March 1995 showed that half the fluent
Welsh speakers questioned would choose to fill in a
vehicle licensing form in English, partly because they
believed the English version of the form was simpler
than the Welsh one.

What's true about forms is equally true about such
things as wall signs. During observation work in one
general hospital, the two following examples of bad
translation:

(i) "Llawr daearol" for "ground floor", literally
"earthly floor"; instead of the more nature Welsh
forms "llawr isaf" or "llawr gwaelod", literally
"lowest floor" or "bottom floor".

(ii) "Cyfres Steryll Crythaol" for "Sterile Cardiac
Suite"; instead of "Lined Ddihainty Galon",
literally "Infection-free Heart Unit", or some
similar descriptive form of words.

Both these are perfect examples of the tendency
described by Emrys ap Iwan to translate literally,
word for word, from the English, rather than thinking
about the meaning of the words involved and the
nature of the things they denote. Signs such as these
fail to perform their main function, namely to convey
information to the public. This is not an argument
based on ideas about standards of language, nor is it
based on any attempt to impose "correct" Welsh on
ordinary Welsh speakers - the simple fact of the
matter is that the two signs described above, and
many others like them are incomprehensible both to
ordinary Welsh speakers and to academic specialists
in the language. The situation is made worse by the
practice of erecting signs which, whilst correct in
terms of choice of words, are littered with spelling
mistakes and typographical errors which would never
be tolerated in English, often rendering the signs
unreadable.

Operating bilingually is a lot easier if an institution
thinks bilingually from the start. There is a great
danger that Welsh language provision will be seen as
an appendix bolted on at the end of any project, and
an unwanted hassle. Nick Gardner has written of the
situation sometimes found in the Basque Country,
where documents were being produced in Spanish
before being translated to Basque, the translation
process being seen as "the last troublesome step to
comply with legal or social requirements before the
'real' Spanish text is launched." (Gardner, N., 1992).

All too often, documents are produced monolingually
in English with no thought being given to how they
will be translated to other languages. As Bhatt points
out, "No agency, however skilled can produce a clear
and readable document if it is given a text in
complex, jargon-ridden English and then told to
translate it literally." (Bhatt A., 1997) Evidence of the
effect of this literal translation was heard in an
interview with a patient:

"Mi ofynnodd [y meddyg] imi lenwi ffurflen
'oeddan nhw wedi darparu yn Gymraeg. a
fedrwn i mo'i deall hi, oherwydd bod yna
gyfieithu clogyrnaidd. Roedd rhaid i mi fynd o'r
neilltu efo'r meddyg a dweud, "Ylwch, yn lie
bod chi'n cyfieithu pam na newch chi ofyn yn
Gymraeg beth dach hi'n feddwl. A deudodd o,
"Cerwch, rhowch siot ar ei gyfieithu hi," medda
fo... A mi nes i addasiadau i'w gwneud hi fel
byddai os oeddach chi eisiau gwybod rhywbeth
yn Gymraeg bod chi'n gofyn y ffordd Gymraeg
amdano fo, ac anghofio’r cyfieithu. Ac 'oedd o'n
deud wrtha i flwyddyn yn ddiweddarach bod
Cymry Cymraeg yn defnyddio'r ffurflen yn
llawer gwell nag oedd y ffurflen dechnegol."
("[The doctor] asked me to fill in a form they
had provided in Welsh. And I couldn't
understand it at all, because the translation was
so poor. I had to take the doctor aside and say,
"Look, instead of translating why don't you ask
in Welsh what you're thinking." And he said,

"Go on, you have a shot at translating it,"... And
I made a few adjustments to make it like it
would be if you wanted to know something in
Welsh, that you'd ask about it in the Welsh way,
and forget about translating. And he told me a
year later that Welsh speakers were using the
form much more easily than the technical form.")

Wherever possible, the English and Welsh versions of
any documents should be prepared in parallel, so that
both versions will be equally readable,
comprehensible and useful. As word processing
technology develops this sort of parallel production is
likely to become increasingly easy.

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Chapter 8- I mage and Substance

By preparing English and Welsh versions in parallel
and regularly comparing the two versions whilst
drawing them up, the quality and clarity of both
versions can be improved, and it can be ensured that
neither contains jargon or meaningless stock phrases.
It must be remembered above all that the purpose of
the leaflets and forms distributed to the public is to
convey information, and that the purpose of
producing leaflets and forms in Welsh is to convey
that information to Welsh speakers more effectively
than could be done in English. Language needs to be
informal and readable, and it will be necessary
sometimes to include English terms where the
equivalent Welsh term is unlikely to be understood by
the target audience. Transferring information rather
than maintaining the purity of the language is the
aim in sight and the one which should have priority
over all other considerations. As a patient said in an
interview "It is one thing to have a translating policy,
but the question is do you provide a service for
people. The principle is that you provide a service for
those who speak Welsh, not that you translate".

If practical, documents can be tested on a sample of
ordinary consumers before being printed en masse -
thereby bringing to light any examples of unclear or
inconsistent use of language, before money and paper
is wasted producing thousands of copies of something
which consumers will reject as unreadable.

Amongst the recent developments in the field of
translation there are two which are particularly
relevant to this report, one in Wales and the other in
England:

(i) On 11J anuary 1999, Bangor University's
Canolfan Bedwyr launched its Cymraeg dir /
Plain Welsh package. The package provides
guidelines for producing documents in a clear
and readable style. One-day courses are already
being held in the Bangor area in connection
with the package. Canolfan Bedwyr also offers a
correction and approval service for Welsh
language documents, marking those documents
considered acceptable with a Cymraeg dir /

Plain Welsh stamp.

(ii) Another exciting development which is likely to
be particularly useful in Wales is the Wordbank
project to collect a bank of official and technical
terms from a number of public services,
including health care. As part of this project, a
number of public bodies have appointed
members of their staff to help draw up glossaries
of terms used in English in any institution's
particular field, together with definitions of
those terms in more straightforward English in

order to give a clear idea of the exact meaning
of every term. After these glossaries have been
compiled (a task which is currently being carried
out) it will then be possible to translate into
other languages on the basis of these definitions,
rather than depending on the term itself every
time. By working on the basis of such
definitions, it is possible that one may be able to
produce "a picture in words or expression in
Welsh of the things they denote," as Emrys ap
Iwan put it, instead of a "clumsy translation of
words from syllable to syllable." Copies of the
glossaries so far compiled are available from the
Institute of Linguists at the following address:

The Institute of Linguists
Saxon House
48 Southwest Street
LONDON SE1 1UN
Tel. 0171 940 3100

8.2.2 Publishing Bilingual Material

It is now standard practice in most public bodies to
publish bilingual documents with the English and the
Welsh on the same page or back-to-back, rather than
producing separate English and Welsh versions.
Although this is not always possible (on account of
such factors as the size and complexity of some
documents) the practice is to be strongly
reccommended for a numbers of reasons:

(i) Bilingual readers who are uncertain of the exact
meaning of any word or phrase in one language
can easily refer to the other version of the text
for an explanation. This is particularly relevant
in relation to official and technical documents
in Welsh, which consumers may wish to read
mostly in Welsh whilst wanting to turn
occasionally to the English when they come
across unfamiliar terms in the Welsh. This very
point was raised in Gwenan Thomas' research
into the experiences of Welsh speaking pregnant
women in south-west Wales:

"The availably of bilingual books was
suggested by several respondents as it would
allow those felt confident to read Welsh to do
so, but at the same time provide a translation
for those who encountered any difficulties."
(Thomas, G„ 1998)

(ii) Non-Welsh speaking staff can distribute
bilingual literature without feeling
uncomfortable, as they might do if they had to
distribute monolingual Welsh documents they
didn't understand. If a Welsh speaking consumer

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WELSH IN THE HEALTH SERVICE:

Chapter 8- I mage and Substance

has an enquiry concerning the literature, the
non-Welsh speaking worker can answer it by
referring to the English version. In the same
way, a non-Welsh speaking worker can to a
certain extent advise consumers who are filling
in bilingual forms in Welsh as he or she will be
able to understand the printed text of the form,
even if he or she does not understand what the
consumer is writing on it.

(iii) If the two versions of a document are produced
together as a single item, no one need ever ask
specially for one or the other of them.

Consumers therefore need never feel that they
are creating problems for a service provider by
asking specially for the Welsh version of a
document. Nor is it necessary to allocate a
particular member of staff to be responsible for
Welsh forms, as currently happens in some
institutions.

(iv) Consumers are not obliged to decide on the spot
in which language they wish to read a leaflet or
fill in a form. It is entirely possible that a person
won't know in which language they wish to give
or receive information until they have a chance
to look at the document in question.

(v) Regularly coming across bilingual forms and
leaflets raises staff consciousness in relation to
the Welsh language and acts as a reminder of
the presence and official status of the language
throughout Wales.

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Chapter 9 - AN INCLUSIVE APPROACH TO WELSH LANGUAGE PROVISION

"Organisations should foster supportive attitudes
towards providing bilingual service, and
encourage staff to participate. Non-Welsh
speakers should not feel threatened or
disadvantaged."(Welsh Language Board, 1996)

"Every worker, whether a Welsh speaker or not,
can facilitate language choice for Welsh
speaking users." (Davies, E., 1999)

As far as can be foreseen, it is beyond any reasonable
doubt that most NHS staff in Wales will be non-Welsh
speakers, and that is only to be expected considering
the linguistic make up of the population in general.

As a large majority amongst NHS staff, non-Welsh
speaking workers are often in a powerful position as
gate-keepers of the entrance points to Welsh language
provision. Often, it is their attitude to Welsh speaking
consumers which determines whether those consumers
get to choose the language of the service they receive
or not.

The fact that the recent steps to improve Welsh
language provision within the Health Service have
provoked a swift and somewhat less than favourable
reaction from some quarters cannot be ignored. The
example below is taken from an article in an NHS
Trust's staff newsletter by an official with
responsibility for the Welsh language, following a
decision that staff should answer the phone with the
Welsh greeting "Boreda" ("Good morning"), before
saying the name of their department in English:

"Even this limited change has stirred up quite a
lot of feeling and has proved to be a great deal
for many to swallow. I had two dozen calls (and
then I stopped counting) all negative, some quite
upset and many angry, and some quite abusive
about the new requirement."

In the same way, in response to a survey by the
Cardiff cell of the Welsh Language Society in May
1998 of the use of Welsh by health care bodies in the
area, a spokesperson for one establishment wrote:

"You will not be surprised to know that there
are elements of cynicism and scepticism
amongst staff who are hard pressed by their
existing commitments and of whom the
overwhelming majority do not speak Welsh and
seldom encounter Welsh speaking patients."

A common enough feeling amongst some staff is that
the present anxiety about Welsh language provision
by public services is unnecessary and irrelevant - a
distraction which draws attention and resources away
from genuinely important problems. Non-Welsh
speaking workers may come to feel that due regard is

not being given to their skills and conscientious work
because they are simply being criticised for being
unable to provide services in Welsh.

On the other hand, it is clear by now that there has
been a substantial growth of goodwill towards the
Welsh language amongst the 81.3% of Welsh people
who do not speak the language. The NOP survey
conducted on behalf of the Welsh Language Board in
March 1995 showed that 77% of people questioned
saw Welsh language as an asset, and 88% saw the
language as something to be proud of. In the field of
health care in particular, a recent survey of midwifes
in north Wales showed there was considerable support
for the use of Welsh in midwifery, both amongst
fluent Welsh speaking midwives and amongst non-
Welsh speakers and less than fluent users of the
language. (Roberts, G„ 1998) Over the last few years,
a broad general consensus in favour of the language
has developed, amongst both Welsh speakers and
those who do not use the language. It is crucially
important to the future of the language and to the
success of Welsh-medium services, that this consensus
is maintained and that the feeling is promoted
amongst all people in Wales that the Welsh language
is something they can own and take pride in. This is
as true in the National Health Service as it is
anywhere else.

There are three main dangers if all the staff of any
establishment are not made to feel that they all have
a part to play in providing for Welsh speaking
consumers:

(i) Too much pressure will be placed on individual
Welsh speaking workers to undertake all sorts of
work related to Welsh. This is particularly true
where Welsh speakers are a small section of the
workforce.

(ii) Individual workers who make a personal effort
to promote Welsh language provision will feel
isolated and lose enthusiasm. One member of
staff described her feelings whilst trying to
provide for Welsh speaking clients in a
institution which operated almost entirely in
English:

"I feel misunderstood, that's the word... A
feeling of isolation and being misunderstood."

(iii) Apathy and a general lack of interest will be
found amongst non-Welsh speaking workers
regarding Welsh language provision, leading to
failure of the provision in the long term.

The evidence collected from interviews, together with
the findings of other researchers, clearly shows that

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WELSH IN THE HEALTH SERVICE:

Chapter 9- An I nclusive Approach To Welsh Language Provision

the attitudes of non-Welsh speaking staff are utterly
crucial to any attempt to improve Welsh language
provision; often significantly more important than
their actual ability or lack of it in the language. Put
simply, not everyone has to speak Welsh fluently to
be part of the provision of quality Welsh language
services. There are two main aspects to what non-
Welsh speaking staff can do to promote the interests
of Welsh speaking patients:

(i) Language sensitivity

(ii) Limited use of Welsh to establish or strengthen
the bond between patients and staff.

9.1 Language Sensitivity

The comments of a number of people in interviews
showed that there is considerable appreciation and
gratitude for the linguistic sensitivity some non-Welsh
speaking staff show when dealing with Welsh
speaking patients. This is true even where staff are
not able to provide any kind of genuine Welsh
language service. For example, there is the testimony
of one mother about the treatment her son received
after an accident:

"Chawson ni ddim siarad Cymraeg, achos doedd
neb ar gael i siarad Cymraeg, ond o leiaf roedd
'na ymwybyddiaeth, a mae hynny'n dweud lot....
Mi gafodd [fy mab] ei gnoco lawr wrth ddod off
y bws ysgol ryw ddiwrnod, a mi aethpwyd a fo
i'r ysbyty agosaf, i casualty.... Mi ddwedodd y
nyrs oedd yn cymryd y manylion, "You're
obviously speaking Welsh", dwedais i, "Yes" a
dwedodd hi, "Does he prefer that?", a dwedais i,
"Yes"... A mi nodwyd hynny ar y ffurflen reit ar
y dechrau... 'On i'n impressed efo'r ysbyty full
stop achos dw i'n meddwl bod y gofal yn
arbennig o dda, ond rhaid cyfadde bod
sensitifrwydd yna wedi ychwanegu rhywbeth -
jyst y ffaith bod nhw sylweddoli a bod nhw
wedi neud nodyn. A mi ddwedodd mwy neu lai
pob meddyg, "I'm really sorry I can't speak
Welsh." Mae jyst yn rhywfath o gydnabyddiaeth
bod nhw'n cydymdeimlo gyda'r sefyllfa."

("We didn't get to speak Welsh, because there
was nobody available to speak Welsh, but at
least there was an awareness, and that says a
lot...[My son] was knocked down getting off the
school bus one day, and he was taken to the
nearest hospital, to casualty... The nurse who
was taking the details said, "You're obviously
speaking Welsh", and I said, "Yes," and she said,
"Does he prefer that?", and I said, "Yes"... And
that was noted on the form right at the start...

I was impressed with the hospital full stop,

because I think that the care was extremely
good, But I must say that that sensitivity added
something - simply the fact that they realised
and made a note. And more or less every doctor
said, "I'm really sorry I can't speak Welsh." It's
just some sort of recognition that they
sympathize with your situation.")

This was reinforced by another parent who had taken
her children to a large hospital in a traditionally
"non-Welsh speaking" area:

"Chwarae teg, efo plant yn arbennig, dw i'n
credu bod nhw'n derbyn y ffaith bod y plant yn
siarad Cymraeg. A mi wnaethon nhw
ymdrechion oherwydd hynny."

("Fair play, especially with children, I think they
accepted the fact that the children speak Welsh.
And they made special efforts because of that.")

Similar praise was heard from consumers for two
specialist hospitals in England which serve parts of
Wales, for their efforts to ensure as good as possible a
provision for their Welsh speaking patients. These
efforts included such things as finding Welsh
language reading material and audio tapes, and
ensuring where possible that parents could be present
to translate between Welsh speaking children and
staff.

Particularly interesting in this regard was the
testimony of one family who had put in motion a
formal complaint about the behaviour of a non-Welsh
speaking health visitor who came to their house. The
family had accepted the fact that a Welsh speaking
health visitor was not always available in their area,
and the clear implication of what they said when
interviewed was that they would not have made such
a serious step as lodging an official complaint had it
not been for some insulting and unprofessional
remarks made by the individual health visitor in
question. The worker's negative attitude to the Welsh
language was the bone of contention, and not the fact
that she personally did not speak Welsh:

"Fel arfer, maegyda ni fenyw arall sydd eto
ddim yn siarad Cymraeg, a dw i byth wedi cael
yr un math o broblemau gyda hi."

("Usually, we have another woman who also
doesn't speak Welsh, and I've never had the
same problems with her.")

Very relevant here is the four quadrant diagram
drawn up by Gwerfyl Roberts of the University of
Wales School of Nursing and M idwifery Studies,
Bangor, showing the corelationship between language
sensitivity and language skills:

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63

Chapter 9- An I nclusive Approach To Welsh Language Provision

Language sensitivity

Language

capability

This model places the same emphasis on developing
language sensitivity as on developing language skills,
in accordance with the idea that the subject of
bilingualism and how to respond to it is as relevant to
monolingual workers as to bilingual ones. The worker
with bilingual skills and language sensitivity (top
right quadrant) will be the most able to deal
successfully with bilingual clients; and the worker
who possesses neither language skills nor language
sensitivity (bottom left quadrant) will be the least
competent in this regard. By looking at language
sensitivity and language capabilities together in this
way, it can be seen that within the four quadrants
there are a number of possible combinations of the
two factors. A sensitive worker without bilingual
skills could make a considerable contribution to the
welfare of a bilingual client, perhaps making a greater
contribution than a bilingual but insensitive worker
might make. Along the two lines defining the four
quadrants, there are two continua of bilingualism and
sensitivity skills along which one can progress, since
all the skills in question are ones which can be
gained, rather than being inherent ones. (Roberts, G.,
1997) By looking at bilingualism and language
sensitivity like this, they can both be seen as natural
components of the culture of "life-long learning"
spoken of in the Welsh Office document Quality Care
and Clinical Excellence published in J uly 1998.
According to this document, in order to ensure the
highest possible standards, the Secretary of State will
"promote a culture of life-long learning and enable
skills to be kept up-to-date." Amongst the "up-to-date
skills" which need to be learned and maintained are
sensitivity and communication skills for dealing with
Welsh speaking patients.

9.2 J ust Enough Welsh to Get By

The range of language used by people in a number of
public situations is often very limited. Often,
especially when telephoning, people simply wish to
perform one simple task - speak to one particular
person, or obtain one particular piece of information.
In this regard, a little language training for
switchboard and front desk staff can make a great
difference. Often, only a small store of Welsh phrases

will be sufficient, e.g. phrases such as "Ga i siarad
a,...?" ("May I speak to...?"), telephone extension
numbers, and the Welsh names of departments.

Things like this, whilst small in themselves, help
Welsh speaking callers to feel that the institution they
are contacting is not one where they are expected to
use English as a matter of course - a common feeling
amongst many Welsh speakers when dealing with
official bodies. Of course, this sort of limited training
will not equip staff for every situation, and when a
more complex enquiry comes in it will sometimes be
necessary to turn to English or pass the caller on to a
member of staff who is more fluent in Welsh.

In the same way, substantial evidence was collected
that many Welsh speaking patients really appreciate
any efforts by staff to communicate with them in
their first language, even if that takes the form of just
a few words or a couple of simple greetings by staff.
Although this sort of simple and superficial greeting
can never be a substitute for genuine opportunities to
communicate fully and freely in the patient's chosen
language, it can be remarkably important for patients
to hear a few words of Welsh in the Anglicised
atmosphere of the surgery or hospital. In her study of
a large general hospital in a traditionally Welsh
speaking area, Gwerfyl Roberts described the efforts
of some non-Welsh speaking nurses to introduce odd
bits of Welsh into their everyday speech whilst at
work:

"Some Anglo-Welsh nurses who have worked on
the ward for numerous years have, over time,
made a conscious effort to learn conversational
Welsh to varying degrees, and interject Welsh
phrases into their verbal interactions with
patients... Nurses on interview, claimed that they
practice limited phrase switching in order to help
bilingual patients feel more at ease... In this
particular study, bilingual patients' response to
limited phrase switching were overwhelmingly
supportive of the practice. Patients particularly
appreciated the respect shown towards their first
language. Moreover, nurses who initiate language
switching in this manner were deemed by patients
as 'mwy cartrefol' (more homely) and ‘mwy agos
atoch' (more intimate)." (Roberts, G., 1994)

On the basis of his own experience as a GP, Dr Carl
Clowes has spoken of the beneficial effect a doctor's
efforts to speak a little Welsh can have on some
Welsh speaking patients:

"J ust learning a few phrases helps put patients
at ease if Welsh is their preferred language - if
patients are relaxed it helps them communicate
effectively and avoid misunderstandings."

WELSH IN THE HEALTHSERVICE:

Chapter 9- An I nclusive Approach To Welsh Language Provision

This is backed up by the comments of Dr Malcolm
Hickey, one of a group of doctors in Barmouth,
Meirionydd, who decided in 1997 to use £8,000 of
fund-holder savings to pay for Welsh language
tuition:

"I don't believe that after a year's course any of
us will be able to conduct a consultation in
Welsh but it can put patients at ease to greet
them in their own language." (Clark, L., 1997)

In interviews, similar comments were made by two
experienced doctors from very different specialities,
and from opposite ends of Wales:

"Dw i'n meddwl bod y cleifon yn
gwerthfawrogi'r ymdrech, hyd yn oed osyn ami
oedd rhaid iddyn nhw newid i'r Saesneg i ddallt
yn iawn."

("I think that patients do appreciate the effort,
even if they often have to turn to English to
understand properly.")

"Yn ami iawn maefe'n werthfawr iawn i
sefydlu'r berthynas empathig yn iaith y galon,
neu iaith gyntaf y person, hyd yn oed os mai
dim ond brawddeg neu ddwy sy'n cael eu
defnyddio."

("Very often it's very valuable to establish the
empathic relationship in the language of the
heart, or the person's first language, even if it's
only a sentence or two that's used.")

The comments of these doctors were confirmed in
interviews with health care consumers, who were
often enthusiastic in their praise for staff who had
attempted to learn a little Welsh. One patient with a
long-term mental illness was particularly generous in
her praise for a doctor who had learnt a few Welsh
phrases to use with patients. If anything, this patient
had a higher opinion of this doctor with her few
Welsh phrases than she had of some of the first
language Welsh speaking staff who were treating her:

"Mae'n rhwydd i siarad a hi, a mae hi yn mynd
mas o'i ffordd, mae'n trio dysgu Cymraeg. "Bore
da" mae'n dweud, neu mae'n stryffanglan ac
mae'n dweud "Pr..pr..prynhawn da," ac mae hi'n
sbesial. Mae'n dweud "diolch yn fawr" a
"croeso" a chymaint o bethau 'ma... A wi'n
hapus yn ei chwmni hi... Wi'n credu bod hi'n
haeddu ei chanmol."

("It's easy to talk to her, and she goes out of her
way, she's trying to learn Welsh. "Bore da," she
says, and she struggles and she says
"Pr..pr..prynhawn da," and she's special. She
says "diolch yn fawr" and "croeso" and so many

things like that... I'm happy in her company... I
think she deserves to be praised.")

Similar praise was heard for another doctor from
another Welsh speaking patient with a long-term
illness:

"'Oedd y consultant yn fantastic... Gafael yn
eich Haw chi. Dyn du oedd o. Deud ambell air o
Gymraeg hefyd. 'O'n i'n gwerthfawrogi hynny,
ac 'oedd o'n dal It yn well, wyddoch chi."

("The consultant was fantastic.... Holding your
hand... Saying a few words of Welsh as well. I
appreciated that, and he understood better, you
know.")

As noted above, the use of such simple greetings and
politenesses can never take the place of proper
communication between the doctor and the patient in
the patient's chosen language. However, considering
how much of a difference these phrases can make as
regards comforting patients and putting them at their
ease, it must be urged that more staff make an effort
to learn and use such phrases with Welsh speaking
patients.

9.3 Welsh as an Essential Skill

Whilst recognising the importance of language
awareness and the use of occasional Welsh phrases to
make patients feel at home, it must be emphasized
before closing this chapter that there will be some
situations where a non-Welsh speaking worker will
have to acknowledge that he or she lacks one
essential skill, namely the ability to communicate in
Welsh. As Sian Wyn Siencyn has noted

"Competence is not necessarily transferable. If
someone is competent in one area it does not
guarantee competence in another."

(Wyn Siencyn, S„ 1995)

Competence is based on knowledge, values and skills
- if a person lacks a particular skill, there is room to
argue that he or she is not competent to do a
particular job, however good his or her other
qualifications are. This is not to say that the worker's
other skills are not valued, simply that one additional
skill is required that he or she does not have.
Certainly, a great deal of professional confidence is
required on the part of a non-Welsh speaking worker
to admit that he or she lacks one essential skill
needed for dealing with consumers who choose to
communicate in Welsh, but this is the very principle
set out for staff in the Professional Code of Conduct
of the UKCC's, the regulatory body for nurses,
midwifes and health visitors in the United Kingdom:

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

65

Chapter 9- An Inclusive Approach To Welsh Language Provision

"Acknowledge any limitations in your
knowledge and competence and decline any
duties or responsibilities unless able to perform
them in a safe and skilled manner."

(UKCC, 1992)

66

WELSH IN THE HEALTH SERVICE

Chapter 10 - RECRUITMENT AND TRAINING

will i iy . HT-..'

T he present shortage of health care staff who are
able to speak Welsh is undeniable and not
easily overcome. The statistics available show
that the percentage of medical staff who speak Welsh
in any one region is consistently lower that the
percentage of Welsh speakers in the general
population. For example, only 21% of the medical
staff of the Gwynedd Hospitals Trust are fluent Welsh
speakers, compared to 72.1% of the population of
Gwynedd, and 51.4% on average between the new
counties of Gwynedd and Conwy. According to the
statistics published by the University of Wales
Hospital, Cardiff, which serves the population of
Cardiff and also provides for patients from all parts of
Wales, only 0.36% of its doctors are able to speak
Welsh, compared with 6.6% of the Capital's general
population and 18.7% of the population of Wales as a
whole.

This statistical picture was confirmed by the
testimony collected from health care staff whilst
researching this report. For example, when enquiring
about mental health care for Welsh speakers, the
following response was received from a spokesperson
on behalf of one Trust:

"As a profession, it's difficult to recruit qualified
workers in the field of mental health. It's even
more difficult to recruit staff who have the
ability to communicate through the medium of
Welsh."

In the same way, one experienced former doctor who
frequently worked through the medium of Welsh,
gave this neat summary of the situation in his area:

"Mae'n anodd iawn i gael meddyg sy'n siarad
Cymraeg - pe bai 'na unrhyw bolisi bod pob
doctor sy'n gweithio yn yr ardal yn gorfod
medru'r Gymraeg, basai'r ysbytai yn wag."

("It's very hard to find a doctor who speaks
Welsh - if there were some sort of policy that
every doctor working in the area had to speak
Welsh, the hospitals would be empty.")

When considering how to address this obvious
shortage, there are two basic options:

(i) Encourage more bilingual speakers to consider
health care as a career, and provide more
opportunities for them to enter the field. As part
of this, we need to address a number of
questions concerning how to make training
courses more relevant to bilingual students, and
to the needs of the bilingual consumers they will
be treating during their working lives.

(ii) Provide opportunities for more non-Welsh

speaking health care staff, and those who have
only a little Welsh, to improve their grasp of the
language sufficiently to be able to use it at
work. In the same way, consideration needs to
be given to providing opportunities for staff
who are Welsh speakers, but who are not used to
using the language professionally, to gain
sufficient confidence and competence to use the
language in their work.

It is likely that a combination of both these
approaches will be necessary if we are to see a
meaningful increase in the number of staff who are
able to provide health care through the medium of
Welsh. These subjects are looked at in the two
Sections below, 10.1 and 10.2. In addition to this, in
Section 10.3, another aspect of training which is
equally relevant to Welsh speakers and non-Welsh
speakers alike is examined - cultural and language
sensitivity and awareness. Section 10.3 follows on
naturally from the points raised in Chapter 9 - An
Inclusive Approach to Welsh Language Provision,
about the importance of language awareness.

10.1 Vocational Training for Welsh Speakers

"Colleges of further and higher education and
other organisations that provide training... will
need to consider the range and content of
vocational courses they provide in order to meet
the demand for people with professional
qualifications who can provide services through
the Medium of Welsh."

(Welsh Language Board 1996)

"To ensure that students develop the knowledge
and skills to practice bilingually, it is necessary
for nursing education programmes to be
delivered in Welsh as well as English."

(Roberts, G., 1996)

Following the recent revival of the Welsh language
and the success of Welsh-medium primary and
secondary education, we are now seeing the first ever
generation of students in Wales who are going into
higher education with standard academic skills in
both Welsh and English. These students know how to
learn in both their languages, and they therefore have
tremendous potential to go on to work bilingually in
their various careers. The WNB (Welsh National Board
for Nursing, Midwifery and Health Visiting) has
committed itself to developing professional education
through Welsh by urging and assisting educational
establishments to provide course or modules within
course through the medium of the language. The

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

67

Chapter 10 - Recruitment and Training

Higher Education Funding Council for Wales has also
stated that the continued development of Welsh-
medium vocational education deserves priority and
the education establishments should be "proactive in
promoting the value of Welsh Medium education in a
vocational context to students and employers."
(Roberts, G., 1996)

At the Conference of the Welsh Society for Nurses,
Midwifes and Health visitors in Gregynog in October
1996, a list of 9 recommendations was drawn up for
the improvement of vocational training in the field of
health care, with a view to attracting more Welsh
speakers to the field and so improving the Welsh
language provision for patients:

(i) The introduction of training in linguistically
and culturally sensitive practices within the
bilingual context in Wales.

(ii) The introduction of teaching and learning
methods which would facilitate bilingual
teaching, such as distance learning, active
learning, and computer-assisted learning.

(iii) The holding of personal tutorial sessions in
the students' preferred language.

(iv) The recognition and emphasis of students'
rights in the University of Wales to present
their written work in Welsh.

(v) The establishment of a central data base
listing Welsh language and bilingual
teaching resources already available.

(vi) Greater provision of suitable language
refresher courses for students and lecturers.

(vii) Networking with other educational
establishments which deal with minority
languages in the field of health care, in order
to share experiences.

(viii) Urge individuals to consider language

sensitive training when they evaluate their
courses.

(ix) Urge statutory and public bodies such as the
UKCC, the WNB, the Royal College of
Nursing, the Royal College of M idwifery, and
Health Service trade unions to commit
themselves to promoting language sensitivity
in health care, and to reflect that
commitment in their policies and practices
(Roberts, G., 1997)

It is at the University of Wales, Bangor, that much of
the work has been done so far towards providing
training courses which are more relevant and more
attractive to Welsh speaking students. Much of that

work has taken place in the School of Nursing and
Midwifery Studies. During 1998 a project was set up
under the title Bilingual Initiatives in Midwifery
Education to develop bilingually various aspects of
the Curriculum of the Diploma in M idwifery. The
project has been funded by the Welsh Office for
3 years, and has received backing from a number of
north Wales NHS Trusts and other relevant bodies.

The 3 main aims of the project are:

(i) The development of key resources: a Resources
Group will be responsible for translating all
documents which form part of the Diploma in
Midwifery course, and for conducting a review
of the bilingual materials already available in
the field of midwifery. It will also work to
develop a bilingual Computer-Assisted Learning
Pack on mechanisms of labour.

(ii) Staff development: the Staff Development Group
has conducted a survey of the language
background and developmental needs of
midwives across north Wales. The results of this
research were published in May 1998, and they
are referred to in several places in this report.
They will form the basis of an assessment of
future needs, such as language refresher courses
and improved bilingual teaching.

(iii) The development of Welsh language midwifery
terms: see Section 7.10 Language, Dialect and
Terminology

Also at the University of Wales, Bangor, Canolfan
Bedwyr provides language refresher courses in both
written and spoken Welsh, including spoken Welsh
courses for would-be midwives in the School of
Nursing and Midwifery Studies. A survey of north
Wales midwives in May 1998 showed that 70%
considered these sorts of courses to be either "quite
important" or "very important". Canolfan Bedwyr has
also experimented with a number of bilingual
teaching methods, including using both languages
with mixed classes of Welsh speaking and non-Welsh
speaking students. Research is also being conducted
into the ways in which students can learn something
in one language and then transfer the information or
skills they have learnt to another language. In the
field of information technology, the staff of Canolfan
Bedwyr are currently preparing a computer grammar
package to be launched in April 1999, with the
intention of helping native Welsh speakers and
proficient learners to use Welsh more and with greater
confidence in the workplace. This package will
include explanatory pages as well as practice
exercises, with the answers to exercises appearing on

68

WELSH IN THE HEALTH SERVICE:

Chapter 10 - Recruitment and Training

the screen afterwards along with a facility to explain
any answers which do not make sense to the user. As
part of the package, there is a facility for keeping a
monthly score of test performance. Any improvement
and progress can therefore be easily noted. This
facility could also be used to record a student's
progress towards completing an NVQ language unit or
similar qualification. Canolfan Bedwyr's Language
Improvement Course is currently being developed for
the Internet, and a temporary version of it can be
found at:

http://hydraulix.bangor.ac.uk/ar/cb/gloywi.htm

During 1998, Gwerfyl Roberts and Liz Paden of
Bangor University spent some time looking at the
patterns of language used in the context of health
care education in Bangor, Galway and Barcelona,
looking specifically at schools of midwifery in these
three places. In all three of these centres, minority
languages - Welsh, Irish and Catalan - are found side
by side with more powerful majority languages -
English and Spanish. Their research showed that
although lectures and seminar groups were not held
in the minority language in schools of midwifery in
any of the three centres, there is considerable scope
for organising personal tutorial classes in the minority
language where both the tutor and the individual
student understand that language. In the same way,
the University of Wales College of Medicine's Welsh
Language Scheme recognises that there are ways of
providing Welsh-medium learning opportunities for
students in small groups and one-to-one sessions,
even when it is not possible for any particular course
to be taught entirely in Welsh.

Amongst the other important developments which are
either planned or already operational, there are
several at the University of Wales College of Medicine
which deserve attention. The College's Welsh
Language Scheme lists a number of developments
which contribute substantially to improving the
opportunities for medical students to develop their
skills in Welsh, and so in turn lead to improved Welsh
language provision for patients. Amongst these are:

• Welsh speaking mentors to be offered to Welsh
speaking undergraduate students in the School
of Medicine, and to be available on request to
students in the Postgraduate School of Medical
and Dental Education.

• The School of M edicine will continue to place
Welsh speaking students in hospitals where
they will have a chance to use their Welsh. In
the Dental School, placements will be
arranged for Welsh speaking students in
Community Dental Services and District

General Hospitals in regions where Welsh is
widely spoken, if students so wish. The
Postgraduate School of Medical and Dental
Education will give students opportunities to
complete their placements in Welsh speaking
areas. In order to facilitate all this, the College
has assessed the linguistic profile of every
District General Hospital in Wales, and
teaching agreements have been established
between these hospitals and the College with
the intention of promoting clinical training
and communication with patients and the
public in Welsh.

• During the clinical period of the
undergraduate curriculum, students will be
given an opportunity to contact Welsh
speaking families as part of their extended
family case study. They will also be able to
conduct their final year extended case studies
in Welsh.

• The College library will provide an appropriate
selection of Welsh reference books for students
who wish to complete some parts of their
studies through the medium of Welsh.

These developments are to be particularly welcomed,
since the evidence of consumers in interviews
suggests that a substantial number of Welsh speaking
doctors are so lacking in confidence when working in
Welsh, or so used to working in English, that they
often do not speak Welsh with some patients who
wish them to do so. This causes patients to feel
uneasy, and feel that they are somehow imposing
unfairly on the doctor by speaking Welsh.

At the University of Wales Institute, Cardiff, (UWIC) a
"Bilingual Studies" module has now been added to
the degree course for speech therapists, including a
practical option on the Welsh language as part of the
module. This is currently the only module of its kind
in Britain, and it is taught through the medium of
English in order to be available to non-Welsh
speaking students. In Section 7.3 - Speech and
Language Therapy the efforts made in Gwynedd to
attract more Welsh speakers to train as speech
therapists were looked at. These included going into
Welsh-medium schools to advertise speech therapy to
students as a possible career, and holding open days
in treatment centres for school and tertiary college
students, with a presentation by a newly-graduated
therapist on the nature of the training and the work.

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

Chapter 10 - Recruitment and Training

10.2 Language Training for non-Welsh Speakers

One very obvious way to increase the number of staff
in any establishment who are able to work through
the medium of Welsh is to offer Welsh language
classes to non-Welsh speaking staff already employed
by the establishment. This is not an easy option, for
the establishment or for staff, since it requires a
strong commitment on both sides to a long process of
learning and practising to gain ability and confidence
in the new language. There are plenty of tales of
Welsh learners who have gone from not having a
word of Welsh to being fluent enough to use the
language every day in their jobs, but it has to be
admitted that these people are rare exceptions. A
great deal more numerous are those who start off
enthusiastically but somehow don't cross the bridge
from being a learner to being a fluent speaker.
Learners will often have their own reasons for
dropping out of a course, but one cannot ignore the
fact that some of the flaws in the teaching system
only serve to increase the drop out rate.

In May 1998, the Welsh Language Committee sent
letters to Health Care Organizations in South East
Wales asking them about aspects of their Welsh
language provisions for patients in their area. Two of
the bodies who responded said that they offer Welsh
language classes to staff, and provide information
about the number of learners who left the classes
early. According to one 60% 'dropped out' and 40%
in another after 3 weeks. In the first, the organization
was paying part of the fee and the staff paying the
rest and the classes held during working hours. In the
second, the staff had to pay the whole cost, and the
classes were held after work in their own time.

Whilst there are some personal and social benefits to
be had from learning Welsh, it is hardly surprising
that so many learners give up on their course so
quickly if they are expected to make such substantial
sacrifices of their money and their free time to obtain
a skill they will use primarily at work. If employers
are serious about helping staff to become sufficiently
fluent in Welsh to use it in the workplace, they will
have to demonstrate this by making it less costly for
learners in terms of time and money to attend classes.
In addition to this, learners do often feel that it is
impossible for them to break into Welsh speaking
social networks, both at work and outside of the work
place. Learners need to be supported to integrate with
fluent Welsh speakers, possibly by allocating one
Welsh speaking member to each learner as a mentor.

M uch work is also needed to help fluent Welsh
speakers to deal sensitively with less fluent speakers,
although attitudes in this regard have substantially
improved in recent years.

10.3 Sensitivity and Awareness Training

Before closing this chapter, there is one aspect of
training for both Welsh speakers and non-Welsh
speakers which needs to be looked at. As described in
Chapter 9 - An Inclusive Approach to Welsh
Language Provision, the attitudes of staff and their
general sensitivity to patients' language needs can
sometimes be equally as important as their ability to
communicate in the patient's chosen language. The
importance of this sensitivity is generally
acknowledged by health care professionals; it is also
acknowledged that training in such sensitivity for
health care staff is an important part of any basic
programme of training. In this context, the
accrediting bodies - the United Kingdom Central
Council for Nurses, Midwives and Health Visitors
(UKCC) and the Welsh National Board for Nurses,
Midwives and Health Visitors (WNB) - and the
professions have considerable responsibility. This
matter was referred to specifically in the Health
Department's 1993 report, Changing Childbirth, which
looks specifically at maternity care but which is also
relevant in the wider context of health care in
general. Changing Childbirth describes the substantial
benefits awareness training can have for both staff
and patients:

"3.1.4 It is essential that the service is designed
to be sensitive to [users'] religious, cultural and
linguistic needs. Staff training programmes
should include these issues, but care must also
be taken to emphasize the need to avoid
stereotyping....

"3.7.4 In areas where there are significant
numbers of women from different ethnic groups,
it is important for staff to be aware of the
cultural and religious beliefs which influence
lifestyle and therefore influence care. Education
should help staff to be sensitive, non¬
patronizing, and above all sympathetic and kind.
This will be of great benefit to the women
involved but it will also help staff. They will
have more confidence in their own abilities to
deal successfully with situations which might
previously have appeared unfamiliar and
therefore intimidating."

These points were reinforced in a Welsh context by
Gwerfyl Roberts of the School of Nursing and
Midwifery at the University of Wales, Bangor, in an
article in Nursing Times in 1996:

"It is essential that, within the context of Wales,
nursing education programmes focus on
language awareness and offer students the
chance to discuss and understand the power

70

WELSH IN THE HEALTHSERVICE:

Chapter 10 - Recruitment and Training

relationships inherent in choice of language in
the health setting." (Roberts, G., 1996)

In connection with this, it is very encouraging to look
at the University of Wales School of Medicine Welsh
Language Scheme which was recently published. This
document describes what specific action a number of
the Schools and Departments will be taking to
incorporate language and cultural awareness into
their curricula. As part of this:

• The School of Medicine will make language
and cultural awareness a part of its
communication skills programme and of
Special Study Modules in the undergraduate
curriculum.

• In the Dental School, language and cultural
awareness issues will be a part of the
Behavioural Sciences course.

• Language and cultural awareness will be
incorporated in to the curricula of the School
of Nursing, and School of Healthcare Studies,
and the Departments of Radiography
Education, Physiotherapy Education, and
Occupational Therapy Education.

This type of initiative should provide a model for
other institutions which train future health care
personnel. However, this is also an issue which needs
to be tackled by service providers themselves. Thus
far, the evidence suggests that, on the whole, the
awareness about Welsh Language Schemes and their
implications is very low amongst the very staff who
have the greatest contact with patients. It is hardly
surprising therefore that there appears to be so much
inconsistency in implementing the patient services
elements of Schemes. Trusts and others should be
using customer care and equal opportunities training
to tackle these issues. The training manual 'Hand in
Hand: Managing in the Bilingual Workplace'
produced by the Welsh Language Board should be of
assistance in this regard.

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

71

Chapter 11 - MONITORING WELSH LANGUAGE PROVISION

A n integral part of any efforts to improve the
standard of Welsh language provision by any
institution is an effective monitoring system
with two main aims:

(i) To measure quality of service against agreed
standards for what should be provided.

(ii) To measure quality of service in terms of the
satisfaction or dissatisfaction of consumers with
what is provided.

In the first of these aims, the standards the institution
in question are aiming at will be those set out in its
own Welsh Language Scheme. In the second, the
factors determining whether consumers are satisfied
with the service they receive or not will be very
variable, and will depend to a large extent on their
expectations of the service. These expectations are
conditioned in their turn by consumers' self-
confidence and their previous experience of using the
same service. In the 1995 Welsh Consumer Council
report, Consumer Expectations, Satisfaction and
Complaints in the NHS in Wales, Glyn Williams and
Robert Harris noted that a low level of complaints
about health care services is often an indication of
low expectations rather than genuine satisfaction, and
concluded that, "at present, most people's
expectations of the NHS are defined in terms of the
service provision to which they have been accustomed
in the past." (Williams, G. & Harris, R„ 1995). It is
difficult to avoid the conclusion that a substantial
portion of Welsh speaking consumers simply do not
expect to be able to use their first language when
dealing with the Health Service. It became clear
during interviews that there is a strong tendency
amongst consumers, even in regions where the Welsh
language is at its strongest, to see medical
establishments as Anglicised places which are
generally unwelcoming to the Welsh language: "sobor
o Seisnigaidd," ("Terribly Anglicised,") was one
member of staff's description of the hospital she was
working in. "Saesneg ydy pob dim, wyddoch chi.

Ewch chi i fewn i'r ysbyty... Saesneg ydy'r pethau
yno," ("Everything is English, you know. You go into
the hospital...things are all English there,") remarked
another patient. Although this situation is obviously
unsatisfactory to many Welsh speaking patients, there
is a tendency to accept it without complaint. Since so
many Welsh speakers' expectations are so low, even
when Welsh language provsion is poor it is often no
worse than they expected, and so they are unlikely to
complain about it.

Even where consumers are dissatisfied, there is often
a great reluctance to complain formally. Some of the

reasons for this are practical - drawing up an official
complaint takes time and energy many people cannot
afford. Other reasons include, ignorance about how to
complain officially - according to the Beaufort
Research survey, 50% of Welsh speakers don't know
whether the NHS in Wales has a published complaints
procedure, and 55% don't know whether the NHS in
their area has a published policy on the Welsh
language. (In one region - the northeast - 74% and
77% were the respective figures). Some of the
patients' other reasons for not complaining formally
were described by Williams and Harris:

"The reluctance of the dissatisfied to express
complaints needs further attention. We have
indentified a number of constraints which deter
dissatisfied people from complaining. They
include the 'politicisation' of certain issues to do
with provision; the stereotyping of protagonists
as political extremists; the fear of recrimination;
the danger of bias in the investigation
procedure... and the desire to reach compromise
positions which will resolve the particular issue
- rather than remove the root cause of a
problem... Furthermore, there are concerns about
under-reporting of complaints. Even when a
complaint is made, it often will not lead the
provider to record the problem, reflect on the
complaint and make the necessary changes.
Because of a tendency to resolve issues
immediately, complaints often go unrecorded.
This also occurs because complainants decide
that once they are satisfied that their particular
problem is resolved, they do not need to
formalise their complaint."

There is a strong and deep-rooted tendency to respect
the medical profession and not to question doctors or
complain about their work. There is also a strong
tendency amongst many patients to allow the
provider of any medical service to decide in what way
it is provided, including any decision about which
language is used. In addition to this, in interviews a
substantial number of consumers and several
members of staff spoke of an unwillingness amongst
native Welsh speakers, particularly those from rural
backgrounds, to complain about the faults of any
service. The Chief Officer of one Community Health
Council raised this point in a traditionally Welsh
speaking area, and Gwenan Thomas found a similar
picture in her research into the experiences of
pregnant women in the Glangwili Hospital catchment
area. Thomas noticed that although many of the
mothers were obviously less than satisfied that they
were obliged to accept a non-Welsh speaking

WELSH IN THE HEALTH SERVICE:

Chapter 11- Monitoring Welsh Language Provision

midwife, none of them had been willing to complain
about it at the time. Thomas quotes two mothers
comments on the subject:

"Fyddwn i'n lico midwife Gymraeg, ond hefyd
dim yn fodlon 'neud dim byd ambwyti fe."

("I'd like a Welsh speaking midwife, but also I
wouldn't be willing to do anything about it.")

"Fyddwn i ddim yn teimlo dylwn i 'neud ffws."

("I'd feel I shouldn't make a fuss.")

(Thomas, G., 1998)

In their report, Williams and Harris saw this tendency
as a characteristically Welsh one:

"There is also a cultural dimension, with the
Welsh tradition of expressing dissatisfaction
through silence and reticence being a major
feature. This is partly a reflection of the desire
not to be seen to be making a fuss...

Furthermore, the more insensitive observer is
unlikely to see the relationship between silent
retreat and dissatisfaction. It is therefore obvious
that the language and cultural sensitivity
training is essential."

(Williams, G. & Harris, R.,1995)

For all the reasons listed above, the process of
monitoring Welsh language provision has to depend
on something more than simply counting complaints.
However, most of the responses received from NHS
Trusts and Community Health Councils during the
research for this report, suggest that it is exactly this
sort of complaint counting which is the main method,
if not the only method, used by many health care
institutions in Wales to monitor the feelings of
consumers about Welsh language provision. In
addition to this, there is a certain amount of evidence
that only formal complaints which are received in
writing are counted as official complaints, and that
there is a tendency to ignore, or a least not to record,
complaints made in person or over the phone. For
example, shortly after speaking with a spokesperson
for one Community Health Council, who claimed that
he had never received any complaints or comments
about Welsh-medium services, an interview was
conducted with a woman who stated that she had
recently complained by phone to the same
Community Health Council about the lack of Welsh
language provision locally for her monoglot Welsh
speaking child.

An indication of what could be done instead of
simply waiting for complaints to come in, can be seen
in the work of one NHS Trust which has published
and distributed a simple but comprehensive bilingual

questionnaire to assess the satisfaction of patients
with its Welsh Language Scheme. Throughout the
questionnaire the emphasis is on ensuring equality
between English and Welsh, with questions referring
to the bilingualism of various services rather than
their availability in Welsh. Patients are asked if they
were able to use "your preferred language", and
whether "your choice of language" was respected,
rather than referring to one language or the other. By
framing the questions in this manner, the message is
emphasized that the Trust is aiming at natural
bilingualism and provision for every patient in his or
her chosen language, and not at winning "special
favours" for Welsh speakers. A number of other Trusts
have committed themselves to carrying out similar
surveys, but it is not clear at present how many
surveys have actually been conducted by now, nor
what the results have been.

In the Welsh Office document Quality Care and
Cilnical Excellence, published in J uly 1998 as a
follow-up to the white paper Putting Patients First, it
is acknowledged that, "the NHS does not have
systematic and comparable information about what
users and carers think about the service it provides."

In response to this problem, it is suggested
establishing a new national survey, to be conducted at
local Health Authority level, of the opinions of
National Health Service users:

"It will ask patients about issues which really
matter to them, such as the ease of access to
services, how long they have to wait for
treatment, and whether they are happy with the
quality of information provided about their care.
A sample of views will be taken from people
treated in each health authority area, giving a
comprehensive national picture of how NHS
Wales is performing from the patient's
perspective."

The results of this survey will be published in annual
reports so that consumers will be able to assess the
progress made by local health services, and compare
their quality with services in other regions. This will
be an excellent opportunity to question health care
consumers about many aspects of their care,
including the effort to meet personal needs - talked
about so much in the White Paper Putting Patients
First. Amongst these needs, of course, there are
language needs, and no national health survey in
Wales would be genuinely comprehensive if it did not
pay attention to the situation of the Welsh language
in the Health Service.

The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

Chapter 12 - VOLUNTARY AND CHARITABLE BODIES

A large number of voluntary and charitable
organisations provide a wide variety of care
and counselling services for patients in Wales.
In addition to this, a number of services within
medical establishments are provided by unpaid
workers from various voluntary groups - during
observation work, it was noted that the main
enquiries desk at one hospital was staffed by members
of the Red Cross, and a wide range of services for
patients in hospitals throughout Britain are carried
out by the Women's Royal Voluntary Service (WRVS).

Although voluntary bodies do not come within the
definition of "public bodies" set out in the 1993
Welsh Language Act, several have been co-operating
with the Welsh Language Board preparing Welsh
Language Schemes. Amongst these are M arie Curie
Cancer Care, Welsh Women's Aid, Barnardos, the
British Diabetic Association, NSF Wales, RNIB, RNID,
and Tenovus. In addition to this, a partnership has
been developed between the Welsh Language Board
and the Wales Council for Voluntary Action, and a
number of useful documents dealing with the Welsh
language in the voluntary sector have come out of
this partnership. The most recent of these, Recruiting
Welsh Speaking Volunteers, raises a number of
important points for voluntary bodies to consider
when attempting to attract Welsh speakers to do
voluntary work, and when supporting such volunteers
in their work. Copies of this leaflet, and of several
others looking at Welsh in the voluntary sector, are
available from the Wales Council for Voluntary Action
in Llandudno.

It should also be noted that a number of voluntary
sector organisations actually provide healthcare
services under contract to and on behalf of Health
Authorities and Trusts or under their supervision. In
such circumstances, voluntary organisations are
agents of those bodies and services should be
provided in line with the Trust's/Authority's own
Welsh Language Scheme. Schemes commit public
bodies to ensure this requirement is included in any
contracts or agreements with third parties and is
monitored to ensure compliance.

Voluntary organisations also produce many of the
leaflets and information packs that find their way into
hospitals, clinics and GP surgeries and are displayed
or distributed to patients. Much of this material is
currently in English only.

It did not prove possible when drawing up this report
to conduct any comprehensive research into Welsh
language provision for vulnerable consumers
voluntary and charitable organisations. Before

drawing any firm conclusions regarding this field of
care, it will necessary to collect a great deal more
information about the following four things:

(i) Which health care services are provided in
Wales by such bodies.

(ii) Who uses these services, and how many of them
could be considered as vulnerable consumers.

(iii) What sort of arrangements have been made so
far for Welsh speaking consumers, and what is
intended will be done in the future.

(iv) To what extent does the present Welsh language
provision meet the needs of Welsh speaking
consumers.

Similarly, more information is needed with regard to
the provision of private businesses, for example
Nursing Homes, which have an important role in
health provision.

WELSHIN THE HEALTH SERVICE:

Chapter 13 - CONCLUSIONS

S et out below is a list of the main general
conclusions of this report. More detailed
conclusions about specific issues are to be
found in the main body of the report:

• According to their own testimony, having the
opportunity to discuss health matters in their
first language does make many Welsh
speaking patients feel more comfortable and
more at ease. This is confirmed by the
testimony of Welsh speaking staff, some of
whom go so far as to state that they can
obtain better information from Welsh speaking
patients about their condition by speaking
Welsh with them.

• On the whole, Welsh speaking patients
appreciate any efforts, however small, to
acknowledge their language and culture and
to communicate with them at least partially in
Welsh.

• In the case of some Welsh speaking patients,
there is room to argue that they cannot be
effectively treated except in their first
language, or in both their languages. This is
especially true in the case of those receiving
speech and language therapy, and of the 4 key
groups described in Section 7.2 above,
namely:

(i) people with mental health problems,

(ii) people with learning disabilities and other
special needs,

(iii) the elderly, and

(iv) young children.

• The longer any course of treatment continues,
and the more talking and counselling the
treatment involves, the more important
language choice becomes in the minds of
Welsh speaking patients. Also, the more
serious the condition and more intensive the
care, the more important language becomes.
Amongst the areas in which this conclusion is
especially relevant are midwifery, care for
those with a chronic or terminal illness, and
psychiatry and psychotherapy.

• On the whole, the responsibility for ensuring
the use of a language in which every one is
comfortable is currently being placed on the
shoulders of the health care consumers rather
than providers. It appears that this situation is
taken for granted as an entirely normal one by
most health care institutions.

• There are two main factors that cannot be
ignored, which prevent Welsh language
development in the National Health Service in
Wales.

❖ A shortage of Welsh speaking staff.

❖ Insufficient consideration of language choice
as a significant factor in health care.

Although the first of these problems cannot be solved
overnight there are already a number of excellent
schemes planned or in place in several institutions to
improve the present situation, either by improving the
language skills of current staff or by recruiting more
Welsh speakers. There is, however, no national
strategy to tackle this issue and as a result there is no
overview of the situation or co-ordination of
measures to improve the position. For example,
educational/training institutions do not seem to be
taking language skills and the linguistic needs of the
bilingual workplace into consideration in allocating
places on courses. This is partly due to the fact that
service providers are not making their needs clear to
these institutions despite commitments to do so in
Welsh Language Schemes. Similarly, accreditation
bodies do not appear to be proactive on this issue.

In terms of the second issue, a great deal can be
achieved by taking the simple step of acknowledging
the Welsh language as an important consideration
when planning provision for patients. If this is not
done, efforts to increase the number of bilingual staff
will make very little difference, since the bilingual
skills of staff are of very little help to patients if there
is no effective system to allocate Welsh speaking staff
to Welsh speaking patients. In general there is very
little consideration or recognition of the Welsh
language as a factor of real importance in the
provision of healthcare. This mindset permeates to
every aspect of the health sector. It can even be seen
clearly in the attitude of the Community Health
Councils. Although their role is to represent the
interests of patients, it appears that, on the whole,
little or no emphasis is placed on the linguistic needs
of patients.

• There is a general lack of awareness amongst
both Welsh speaking and non-Welsh speaking
staff and patients regarding Welsh Language
Schemes. The effective operation of Language
Schemes on an everyday basis still depends to
a large extent on the effort and commitment
of individuals - either individual members of
staff who are aware of the importance of
language choice; or individual patients who
are confident enough or stubborn enough to
insist on receiving services in Welsh.

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75

Chapter 13 - Conclusions

• Very few health care institutions have
effective systems to identify and record
patients' language choice and to pass that
information on. Even fewer actually take steps
to act on the basis of any such information
after obtaining it. In the face of this lack of
proper language identification systems, Welsh
speaking staff and patients depend on
unreliable and intuitive methods to recognise
fellow Welsh speakers.

• Because health care providers do not consider
language choice when allocating particular
staff to particular patients, even when Welsh
speaking staff are available, if patients do
wish to receive service in Welsh they are often
obliged to personally turn away any non-
Welsh speaking worker who is sent to treat
them. This often leads to personal
confrontation and unnecessary bad feelings.

• Contrary to the commitments made in every
Welsh Language Scheme prepared by health
care institutions in Wales, patients and their
families are still having to make special
requests for service in Welsh. Where a Welsh
language service is offered without patients
having to request it, this is usually the result
of independent action by individual workers.

• The communication skills of bilingual staff are
currently being wasted because there is no
proper recognition of bilingualism as a
valuable professional skill. The other side of
this coin is that Welsh speaking patients are
being deprived of Welsh language provision
which could be available to them if language
choice was considered as a significant factor
when allocating specific staff to specific
patients.

• Non-Welsh speaking staff often do not feel
part of efforts to improve Welsh language
provision, and this can lead to apathy and bad
feeling amongst them regarding such efforts.

• One unpleasant but unavoidable conclusion is
that there are a small number of health care
workers who are creating genuine
unhappiness, and in some cases adding to the
problems of patients and families who are
already under stress, by allowing their own
prejudiced attitudes to bilingualism and the
Welsh language to determine the advice they
give to clients. The most obvious example of

this is the small number of health visitors,
therapists and other staff who have advised
parents not to speak Welsh to their children.

• All the above are exacerbated by a lack of
strategic planning within the Service as far as
Welsh language provision is concerned. The
Welsh Office failed to provide a lead and this
is reflected in the fact that circulars, guidance,
guidelines etc. have not been attuned to the
needs of a bilingual population.

• There is a lack of statistical information that
would enable meaningful clinical conclusions
to be made in relation to language.

• There is little evidence that the provision of a
meaningful service to Welsh speakers is
perceived, as it should be, as part of the Equal
Opportunities agenda and as an important
element in the quality of service agenda.

76

WELSH IN THE HEALTH SERVICE

Chapter 14 - RECOMMENDATIONS

"Much can be achieved with the resources
already at the disposal of the authorities and
further progress can be made as and when the
opportunity arises and at minimum cost."

Welsh Office Circular on the Welsh Language in
the National Health Service, March 1975

The following list of recommendations is based on the
themes that were brought to light in the main body of
this report. The recommendations are loosely grouped
into sections and under each section there is a general
discussion on the contribution that various
organisations and groups can make towards
implementing the recommendations.

1. The Status of the Welsh Language/

Principles of Care

• As part of any programme to improve the
quality of health care services, we should aim
in the long term towards removing the burden
of responsibility for ensuring a common
language between providers and consumers
from the shoulders of patients, and placing it
to a far greater extent on the institutions
providing health care.

• At the same time, we must aim towards a
fundamentally different way of thinking,
which extends any definitions of quality of
care to include language choice along with
other important non-clinical considerations.

• The clinical need for Welsh language provision
in some fields needs to be acknowledged,
including speech and language therapy and
the four key groups described in Section 7.2
above, namely:

(i) people with mental health problems,

(ii) people with learning disabilities and other
special needs,

(iii) the elderly, and

(iv) young children.

In this context, the need for detailed research into the
clinical effects of not providing a Welsh service in the
fields in question must be noted. In order to facilitate
such research, there is a need to begin to collect
specific health statistics for Wales (and perhaps Welsh
speakers) in order to allow comparison with other
groups. This already happens with Irish and ethnic
minorities in England.

• In order to avoid the present skills wastage,
bilingualism and the ability to speak Welsh
must be acknowledged as valuable
professional skills in the field of health care.

CONTRIBUTORS

National Assembly for Wales

As the organisation with overall responsibility for the
health service in Wales, the National Assembly has a
key strategic role.

It is the Assembly (and previously the Welsh Office)
which sets the tone for health services in Wales and
its influence is far-reaching. It gives a lead in most
aspects of the Service. M uch of this is done through
the publication of policy and good practice
documents, often in the form of circulars. These
documents present Government policies on a practical
level and steer the priorities of public organisations
and other bodies.

One of the policies of the Government enshrined in
the Welsh Language Act 1993 is that the Welsh and
English languages should be treated equally in
providing services to the public in Wales. It might be
expected therefore that documents emanating from
the Welsh Office would incorporate the linguistic
context together with other considerations, in order to
pass on the Government's expectations in this regard
to service providers. The inclusion of this
consideration should be the norm and this would help
to remind those charged with implementing policies
of the need to plan and provide a service with two
languages in mind.

Apart from the specific circular "Welsh Language in
the National Health Service", March 1975 referred to
several times in this study, there is little evidence to
suggest that the linguistic context of the health
service in Wales has been reflected in policy
documents, guidelines etc emanating from the Welsh
Office. There is also little evidence to suggest that the
recommendations of the 1975 circular have been
followed up in any meaningful way.

If attitudes towards providing services in Welsh are to
change within the health service, then the National
Assembly must provide a strong lead. There should be
a mechanism whereby when each new initiative,
policy etc is considered, it is also considered from the
point of needing to provide a bilingual service. This
consideration should then permeate any associated
documentation or advice. The Assembly must make it
clear to the service in its words and actions that this
is an important service issue and a key element in
ensuring a quality service for the public in Wales.
Also, that it is central to the Assembly's aim of
ensuring equal access to services for all, and part of
the Government's broader "Service First" agenda.

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Chapter 14 - Recommendations

The Professions

Professional organisations play a key role in shaping
the attitudes of their members. Many 'professional'
pronouncements already point to the need to focus on
the needs of the individual in order to ensure a
service of a high professional standard. However,
given the shortcomings highlighted by this report, a
more proactive approach is required in terms of
increasing the profile of the importance of bilingual
provision in Wales and a sensitive approach to
linguistic matters.

Educational/Training Institutions and Accreditation
and Regulatory bodies

These organisations should ensure that health care
courses in Wales pay sufficient regard to the context
of the bilingual workplace and service in Wales.
During their training period is the perfect time to
instil into prospective health workers the importance
of language and language sensitivity. Those who
accredit and regulate courses can help to ensure that
this happens.

Client representatives and those representing the
public interest

The obvious group here is the Community Health
Councils, however other public organisations such as
the Mental Health Act Commission also represent the
interests of patients as do many voluntary bodies.
Clearly, any organisations which represent the
consumer in Wales must ensure that as part of this
they represent the interests of Welsh speaking
consumers. In this they have an important role to
play in raising the profile of the language as an
integral part of service provision. Similarly
organisations such as the Audit Commission,
Inspectorates and other bodies who evaluate service
quality need to evaluate the quality of Welsh
language service provision as part of their general
remit.

Health care providers

The providers themselves need to ensure that the
recommendations above are implemented at the
operational level. For this to happen there needs to be
a corporate investment into the aims and principles
noted. Trusts, etc need to send clear messages to their
employees with regard to the importance of these
matters. The message also needs to reach voluntary
bodies and private care providers who are part of the
delivery of health care in Wales.

Others

The NHS Equality Unit, which is now based at lechyd
Morgannwg Health, should ensure that linguistic
matters are included as an integral part of their equal
opportunities agenda. It would be helpful if funding
could be found for a specific member of staff to
specialize in this aspect.

2. Recruitment/ Training

• More effective communication is required
between service providers,
educational/training bodies, funding
organisations and accreditation/ regulatory
bodies on the numbers of Welsh speakers
needed. As part of this, there needs to be a
discussion as to whether training
establishments have enough places to fulfil the
needs of the service.

• The efforts of bodies such as the University of
Wales School of Nursing and Midwifery,
Bangor, and the University of Wales College of
Medicine, Cardiff, to make their training
courses more relevant and more attractive to
Welsh speaking students and to introduce
language awareness/sensitivity training are
very much to be welcomed. The challenge now
for these two establishments is to build on
these foundations; and the challenge to other
similar bodies is to follow their example and
begin developing in the same direction.

• The work done in Gwynedd in recent years to
attract more Welsh speakers into the field of
speech and language therapy is to be strongly
recommended as an example to other health
care employers. If more is not done to show
bilingual young people how a career in health
care could be relevant and attractive to them,
any improvement in levels of Welsh language
provision for patients will be very slow
indeed.

• In general, Welsh language classes for non-
Welsh speaking staff need to be more
accessible, more attractive and more
structured. Learning a language is a major
commitment which requires considerable
perseverance, and this burden should not be
added to by holding classes at inconvenient
times, or by asking staff to give too much of
their own free time and money to attend
classes.

• Specifically, more support is needed for
independent practitioners within the National

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WELSH IN THE HEALTH SERVICE:

Chapter 14 - Recommendations

Health Service, such as GPs, dentists and
pharmacists, who wish to learn Welsh or
improve their Welsh, e.g. bursaries, paid leave,
opportunities to share jobs in order to free up
time for study.

• As a matter of urgency, it should be ensured
that ambulance drivers and ambulance service
telephonists receive sufficient language
training to be able to deal appropriately with
Welsh names and addresses, and are able to
record them accurately and correctly. As
shown in Section 7.7 Accident and Emergency
Services, any failings in this section of the
Health Service can seriously endanger lives.

• As part of the process of acknowledging the
communication skills of bilingual staff, it is
recommended that a recognised vocational
qualification in bilingual communication skills
be established. By gaining this qualification,
students would show that they were able to
communicate clearly and effectively in both
Welsh and English in both writing and speech.
Opportunities to gain such a qualification
should be available to students of medicine,
nursing and care as part of their courses, and
to members of staff of health care
establishments as part of their ongoing job
training. In this way, the bilingual skills which
staff already have would be officially
acknowledged, and other staff would have the
opportunity to gain such skills in an organised
and directioned manner.

• In order to avoid situations of tension arising
from personal confrontation between Welsh
speaking patients and non-Welsh speaking
staff, much more work is needed to raise the
awareness of staff about the linguistic identity
and needs of the patient and about the Welsh
Language Scheme of the institution they are
working for. This is particularly important in
the areas, such as health visiting, where there
is evidence that some staff have been
behaving unprofessionally towards Welsh
speaking clients.

• In the same way, every institution which
offers training for health care staff and those
who fund, accredit and regulate courses,
should consider whether sufficient attention is
being given to issues of language and cultural
awareness in courses.

• In general, much more work needs to be done
to draw non-Welsh speaking workers into the
process of implementing Welsh Language

Schemes. Present levels of provision for Welsh
speaking patients will never be improved upon
if staff are not aware of what they are
expected to do to facilitate that provision.
Little progress will be achieved either unless
all members of staff feel they have a genuine
part to play in the operation of any Scheme
and see its relevance to the equal
opportunities agenda and the provision of a
quality service.

CONTRIBUTORS

National Assembly for Wales

It is clear that a national strategy with regard to
bilingual skills is required. Any form of strategic
approach to recruitment problems within Wales is
dependent upon the National Assembly for Wales.
Only the Assembly can provide the overview that is
required.

As such, the first step will be to identify shortfalls (in
conjunction with Trusts and others) in the numbers of
bilingual staff by speciality and area. Where it is clear
that there is a national problem, the Assembly should
take steps to tackle this. This might involve co¬
ordinating an all-Wales recruitment campaign. It
might also involve allocating funding to sponsor
students in specialities where there are shortages -
this approach worked well with speech and language
therapy in Gwynedd and could be applied elsewhere,
where necessary.

The Assembly should also liaise with education
providers in order to alert them to these issues. In the
case of nurse education, the Assembly has a
particularly influential role because the funding for
courses comes directly from the Education Purchasing
Unit within the Assembly. This influence should be
used to ensure that the above recommendations are
implemented. In particular, theEPU, having consulted
with service providers, specifies the numbers of
nursing personnel by speciality to be registered on
courses annually. In their liaison with the Trusts the
EPU should also establish the numbers of bilingual
personnel needed to implement Welsh Language
Schemes commitments and include this in the brief to
the Colleges.

The Assembly should review the numbers of training
places available and assess whether they are sufficient
to provide service providers in Wales with enough
suitably skilled bilingual employees to deliver services
in Welsh and English on a basis of equality.

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79

Chapter 14 - Recommendations

Professional bodies

Professional bodies should use their influence to
encourage education and training providers to reflect
the above recommendations in their courses. Where
professional bodies themselves are directly involved
in training provision, they should ensure that the
same principles are taken into account.

Education/Training Institutions and Accreditation
and Regulatory Bodies

Clearly these organisations are crucial to the
implementation of the recommendations. In terms of
recruitment, the Education/Training Institutions
should take account of the needs of the service
providers for staff who can provide a bilingual
service. As well as making sure that courses are
attractive and accessible to Welsh speakers both
Institutions and Accreditation bodies should seek to
ensure that courses prepare both English and Welsh
speakers for work in the bilingual workplace in terms
of linguistic awareness and sensitivity.

Health Care providers

As this report shows, health care providers have much
to do to increase awareness amongst their staff about
Welsh language service provision. This should be
presented in the context of customer care, equal
opportunities and an emphasis on patient-focused
care. Providers do have a crucial role in alerting the
National Assembly and the colleges to their needs in
terms of bilingual staff. Also, as the example of
speech and language therapy in Gwynedd shows,
there is much that can be done on a local level to
increase the recruitment of Welsh speakers where
there are shortfalls.

3. Practical Considerations with regard to
service delivery

• First and foremost, there is a clear need to
immediately establish an effective and
comprehensive system to identify and record
which languages patients use in their every
day lives, so that this may be reflected in the
care they receive. Along with any other
essential information about them, this record
should go with the patient throughout his or
her contact with the Health Service. When a
GP presents information about a patient's
condition before he or she is admitted to
hospital, information about the patient's
language choice should be included in the
section noting his or her other personal
details. When a patient is admitted to a

hospital or other medical establishment at
short notice, information about the patient's
language choice should be included with his
or her other personal details when he or she is
registered by staff. This information should be
acted upon to ensure that patients are treated
in the language in which they are most
comfortable, whenever that is possible. It is
acknowledged that it will not always be
possible to provide service in Welsh to every
patient who wishes to receive it, and in some
institutions the opportunities for providing a
Welsh language service will be few and far
between. However, the proper
acknowledgement of the importance of
language choice and a commitment to record
that choice, will be a first step towards
improving the provision for Welsh speaking
patients. Hospitals already record things such
as patients' religion and dietary requirements,
and act on the basis of those records to make
any patient's stay in hospital as pleasant as
possible. It is high time that this consideration
of personal needs was extended to include
language choice.

• In order to avoid the present situation where
patients have to depend on their intuition and
local knowledge to identify Welsh speaking
staff, such staff must be easily recognisable.
This could be by a system of standardized and
clearly visible badges. In addition to this, the
locations in any establishment where service is
available in Welsh should be clearly identified.
In this regard, the Welsh Language Board's
Working Welsh scheme is to be very much
recommended, since it includes - as well as
badges for staff - explanatory sheets and desk
and wall signs in the same style as the badges,
to reinforce the message about in which part
of an establishment a Welsh-medium service
can be expected.

• Since the majority of Welsh speakers have
long since grown used to receiving service
only in English in official situations, they are
unlikely to expect or demand Welsh language
provision is such situations. For this reason,
until it is firmly established that a patient is
not Welsh speaking, or that he or she wishes
to receive service in English for some other
reason, service in Welsh should be offered to
him or her if it can be provided. Welsh
language service should be offered in such a
way that there is no suggestion that it is
unusual or inconvenient for the provider, and

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WELSH IN THE HEALTHSERVICE:

Chapter 14 - Recommendations

without any pressure on the patient to accept
or refuse it.

• Wherever practical, services should be planned
to ensure that bilingual workers are able to
make full use of their language skills, by
allocating them to patients who wish to
receive service in Welsh. Where current
arrangements/ procedures militate against this,
because of their inflexibilities, they should be
changed.

• If a period of treatment or care is likely to
continue for a substantial period and the
caring relies on one member of staff, every
effort should be made to allocate a Welsh
speaking member of staff to any Welsh
speaking patient who wishes that. Amongst
the areas to which this recommendation is
particularly relevant are midwifery, and care
for those with a chronic or terminal illness.

• When implementing Welsh Language Schemes,
Health Service Trusts need to give greater
attention to non-clinical aspects of health
care, such as chaplaincy services, and
distractions such as radio, television and
magazines. If an effective system to record
language choice is developed as recommended
above, the information collected through such
a system can then be used to see which
patients are likely to want to see a Welsh
speaking chaplain or want to receive Welsh
language magazines or radio and television
programmes.

• Programmes to monitor the effectiveness of
Welsh language provision and consumer
satisfaction with it have to go beyond the
process of counting complaints and dealing
with them individually. More proactive
methods have to be adopted.

Visible Welsh

• In order to be useful and meaningful, Welsh
and bilingual signs and documents need to be
of a consistent standard. Incorrect or unclear
signs or documents are a waste of scarce NHS
resources, without being of any real help to
Welsh speaking consumers. In order to
improve the present situation where incorrect
Welsh language materials are widely tolerated,
it will be necessary to move beyond the
mindset which sees Welsh language materials
in an iconic fashion, towards a reasoned
assessment of the actual usefulness of every
document and sign produced.

• In order to ensure the quality and correctness
of Welsh language materials, consideration
should be given to moving towards parallel
production methods for materials in English
and Welsh, rather than the linear system
currently used in many places, where Welsh
materials are produced on the basis of English
ones.

• In terms of materials produced by voluntary
and private sector organisations, distribution
arrangements need to be tightened to ensure
that only bilingual material (where it exists) or
both English and Welsh material is made
available for patients. Where these
organisations currently only produce English
only material, Trusts etc should impress upon
them the importance of bilingual material for
Wales.

CONTRIBUTORS

Although the majority of recommendations in this
section clearly fall within the scope of the NHS
Trusts, the National Assembly for Wales also has a
role in providing a lead on some of the issues in order
to encourage consistency throughout Wales. For
example, the Assembly should ensure that any
working arrangements or structures it recommends
should facilitate rather than frustrate a bilingual
service. Also patient representatives in their general
monitoring of services and procedures should be
checking that the above measures are in place and
working satisfactorily.

4. MISCELLANEOUS

• All private practitioners within the NHS in
Wales, GPs, dentists, pharmacists etc. should
be made subject to the Welsh Language Act.

• The Assembly should examine the lack of
statistical information on the experiences of
Welsh speakers in specialities where this is
likely to be different to other groups e.g.
psychotherapy, and take actions to ensure that
such data can be collected and utilized for
service planning and delivery purposes in the
future.

Information Services:

• If it is decided to set up an NHS Direct
telephone enquiries system on the basis of the
pilot schemes carried out in England, serious
consideration should be given as to how
Welsh speaking callers can be provided for.

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81

Chapter 14 - Recommendations

As part of this, the ways in which the latest
telephone technology can be used to integrate
language choice as part of a comprehensive
service to patients need to be looked at.

Additional Research:

• More research is needed into the work of
health care providers such as GPs, dentists and
pharmacists, who provide medical services as
independent practitioners within the National
Health Service and also private nursing
homes. Their role in provision for Welsh
speaking patients, their needs when trying to
provide a bilingual service, and their attitudes
towards the Welsh language and its
importance, all need to be examined.

• In the same way, further research is needed
into the role and importance of voluntary and
charitable bodies in providing health care for
Welsh speaking patients.

• Research into the extent to which the Welsh
Office Circular on the Welsh language in the
National Health Service, March 1975, has been
pursued may prove useful in clarifying the
focus which is now required to address the
recommendations springing from this Report.

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BIBLIOGRAPHY

Aitchison, J. & Carter, H. (1994)4 Geography of the
Welsh Language. Cardiff: University of Wales Press

Audit Commission (1993) What Seems to be the
Matter: Communication Between Hospitals and
Patients. London: HMSO

Balarajan, R, & Raleigh, V.S. (1995) Ethnicity and
Health in England. London: NHS Executive, NHS
Ethnic Health Unit

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The Scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales

85

Chapter 14 - Recommendations

THE WELSH LANGUAGE SCHEMES PREPARED BY THE
FOLLOWING INSTITUTIONS UNDER THE 1993 WELSH
LANGUAGE ACT WERE STUDIED

Bridgend and District NHS Trust

Bro Taf Health Authority

Carmarthen and District NHS Trust

Ceredigion and M id Wales NHS Trust

Clwydian Community Care NHS Trust

Gian Clwyd District General Hospital NHS Trust

Gwent Health Authority

Gwynedd Community Health Trust

Gwynedd Hospitals NHS Trust

lechyd Morgannwg Health

Llandough Hospital and Community NHS Trust

LlanelIi/Dinefwr NHS Trust

North Wales Ambulance Service NHS Trust

North Wales Health Authority
Pembrokeshire and Derwen NHS Trust
Powys Health Care NHS Trust
Rhondda NHS Trust

University Hospital of Wales Health Care NHS Trust
University of Wales College of Medicine

UKCC (United Kingdom Central Council for Nursing
Midwifery and Health Visiting)

Velindre Hospital NHS Trust

Welsh Ambulance Services NHS Trust

Welsh Common Health Services Authority

WNB (Welsh National Board for Nursing Midwifery
and Health Visiting)

Wrexham Maelor Hospital NHS Trust

WEB SITES USED:

BBC Wales State of the Nation: http://www.bbc.co.uk/stateofnation/wales/health
British Stammering Association: http://www.stammer.demon.co.uk
Canolfan Bedwyr: http://hydraulix.bangor.ac.uk/ar/cb/cb.htm

Centre for the Standardisation of Welsh Terminology:http://weblife.bangor.ac.uk/adranadd/courses.cst.html (English)

http://weblife.bangor.ac.uk/adranadd/cyrsiau.cst.html (Welsh)

Department of Health: http://www.doh.gov.uk
Disability on the Agenda: http://www.disability.gov.uk
HMSO Official Documents: http://www.official-documents.co.uk
Institute of Rural Health: http://home.rednet.co.uk/homepages/irh
Institute of Linguists: http://www.iol.org.uk

National Assembly for Wales: http://www.assembly.wales.gov.uk (English) or http://www.cynulliad.cymru.gov.uk (Welsh)

Patients' Charter: http://www.servicefirst.gov.uk/list/wepatient.htm (English) or
http://www.servicefirst.gov.uk/list/wpatient.htm (Welsh)

Royal College of Speech and Language Therapists: http://www.rcslt.org

University of Wales College of Medicine: http://uwcm.web.cf.ac.uk

UKCC United Kingdom Central Council for Nursing, Midwifery and Health Visitors: http://www.ukcc.org.uk)

Wales Council for Voluntary Action: http://www.fundraising.co.uk/services/wcva.html
Welsh Language Board: http://www.netwales.co.uk/byig
Welsh Office: http://www.wales.gov.uk
Western Mail: http://www.totalwales.com
Y Lolfa Directory: http://www.ylolfa.wales.com

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